Healthcare Provider Details

I. General information

NPI: 1780979583
Provider Name (Legal Business Name): BELLA VISTA RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 E NANCE ST
MESA AZ
85215-1485
US

IV. Provider business mailing address

PO BOX 22243
MESA AZ
85277-2243
US

V. Phone/Fax

Practice location:
  • Phone: 480-305-3160
  • Fax:
Mailing address:
  • Phone: 480-305-3160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 12033
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DIANA MARIE KYRISCH
Title or Position: PRESIDENT
Credential: LCSW
Phone: 480-305-3160