Healthcare Provider Details

I. General information

NPI: 1063600542
Provider Name (Legal Business Name): MOUNTAIN VALLEY COUNSELING ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 E UNIVERSITY DR SUITE 6
MESA AZ
85201-5945
US

IV. Provider business mailing address

145 E UNIVERSITY DR SUITE 6
MESA AZ
85201-5945
US

V. Phone/Fax

Practice location:
  • Phone: 480-962-7808
  • Fax: 480-962-0560
Mailing address:
  • Phone: 480-962-7808
  • Fax: 480-962-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH-1852
License Number StateAZ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. MARCY WILKERSON
Title or Position: OWNER
Credential: CPA
Phone: 480-962-7808