Healthcare Provider Details

I. General information

NPI: 1124649777
Provider Name (Legal Business Name): DIVINE CHANGING HANDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 E MCKELLIPS RD STE 101
MESA AZ
85203-2753
US

IV. Provider business mailing address

1550 E MCKELLIPS RD STE 101
MESA AZ
85203-2753
US

V. Phone/Fax

Practice location:
  • Phone: 480-597-4951
  • Fax: 480-597-3689
Mailing address:
  • Phone: 480-597-4951
  • Fax: 480-597-3689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: SIRSANDRA SCOTT
Title or Position: OWNER
Credential:
Phone: 702-773-2872