Healthcare Provider Details

I. General information

NPI: 1417593575
Provider Name (Legal Business Name): OBSIDIAN HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13321 W INDIAN SCHOOL RD STE A107
LITCHFIELD PARK AZ
85340-4339
US

IV. Provider business mailing address

13321 W INDIAN SCHOOL RD STE A107
LITCHFIELD PARK AZ
85340-4339
US

V. Phone/Fax

Practice location:
  • Phone: 623-293-2232
  • Fax: 623-321-9524
Mailing address:
  • Phone: 623-293-2232
  • Fax: 623-321-9524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH GRACE
Title or Position: CONSULTANT
Credential:
Phone: 602-696-3556