Healthcare Provider Details

I. General information

NPI: 1194592824
Provider Name (Legal Business Name): PREMIER TRAUMA COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 E BASELINE RD STE 105
MESA AZ
85206-4616
US

IV. Provider business mailing address

4540 E BASELINE RD STE 105
MESA AZ
85206-4616
US

V. Phone/Fax

Practice location:
  • Phone: 480-272-8944
  • Fax:
Mailing address:
  • Phone: 480-272-8944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES SIEFFERT
Title or Position: PARTNER
Credential: DC
Phone: 480-272-8944