Healthcare Provider Details

I. General information

NPI: 1043140775
Provider Name (Legal Business Name): LIVING AND BALANCE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 N COUNTRY CLUB DR STE 102
MESA AZ
85201-4981
US

IV. Provider business mailing address

736 N COUNTRY CLUB DR STE 102
MESA AZ
85201-4981
US

V. Phone/Fax

Practice location:
  • Phone: 602-314-6312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARIE DAVIS
Title or Position: CEO
Credential:
Phone: 602-403-5160