Healthcare Provider Details

I. General information

NPI: 1699674143
Provider Name (Legal Business Name): MESA PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

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

864 W SOUTHERN AVE
MESA AZ
85210-4900
US

IV. Provider business mailing address

864 W SOUTHERN AVE
MESA AZ
85210-4900
US

V. Phone/Fax

Practice location:
  • Phone: 602-690-6901
  • Fax:
Mailing address:
  • Phone: 602-690-6901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TAHLIL SCOTT
Title or Position: MANAGER
Credential:
Phone: 480-478-0418