Healthcare Provider Details

I. General information

NPI: 1386957645
Provider Name (Legal Business Name): SUPERSTITION SPRINGS COUNSELING SERVICES OF ARIZONA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7254 E SOUTHERN AVE SUITE 123
MESA AZ
85209-2786
US

IV. Provider business mailing address

7254 E SOUTHERN AVE SUITE 123
MESA AZ
85209-2786
US

V. Phone/Fax

Practice location:
  • Phone: 602-617-6595
  • Fax: 480-324-0747
Mailing address:
  • Phone: 602-617-6595
  • Fax: 480-324-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLCSW-10373
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberLCSW-10373
License Number StateAZ

VIII. Authorized Official

Name: MRS. MARY MICHAELLE HENNESSEY-PEIRCE
Title or Position: PRIVATE PRACTITIONER
Credential: LCSW
Phone: 602-617-6595