Healthcare Provider Details

I. General information

NPI: 1669191771
Provider Name (Legal Business Name): A DIFFERENT OUTLOOK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5646 E MAIN ST STE 5
MESA AZ
85205-8800
US

IV. Provider business mailing address

1923 E BROADWAY RD
PHOENIX AZ
85040-2411
US

V. Phone/Fax

Practice location:
  • Phone: 602-675-9377
  • Fax:
Mailing address:
  • Phone: 602-566-2249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ASHLEY MOORE
Title or Position: CEO
Credential:
Phone: 602-566-2249