Healthcare Provider Details

I. General information

NPI: 1396644894
Provider Name (Legal Business Name): MACY EIDE MS, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2026
Last Update Date: 11/02/2026
Certification Date: 11/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 S CENTER ST
MESA AZ
85210-1306
US

IV. Provider business mailing address

16412 S 18TH DR
PHOENIX AZ
85045-1628
US

V. Phone/Fax

Practice location:
  • Phone: 763-331-2627
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-24484
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: