Healthcare Provider Details

I. General information

NPI: 1144157272
Provider Name (Legal Business Name): COMMUNITY IMPACT COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7731 E HOLMES AVE
MESA AZ
85209-3447
US

IV. Provider business mailing address

7731 E HOLMES AVE
MESA AZ
85209-3447
US

V. Phone/Fax

Practice location:
  • Phone: 262-424-8711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN RACHELLE COFFEY
Title or Position: CEO
Credential: COFFEY
Phone: 262-424-8711