Healthcare Provider Details

I. General information

NPI: 1144625765
Provider Name (Legal Business Name): ELEVATE ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 N LADERA CIR
MESA AZ
85207-0810
US

IV. Provider business mailing address

3208 N LADERA CIR
MESA AZ
85207-0810
US

V. Phone/Fax

Practice location:
  • Phone: 480-428-8022
  • Fax:
Mailing address:
  • Phone: 480-428-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. WALTER NEIL SIMMONS
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD, MPH, FACEP
Phone: 480-428-8022