Healthcare Provider Details

I. General information

NPI: 1679356349
Provider Name (Legal Business Name): AMBEDO COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 E VALLEY AUTO DR STE 201
MESA AZ
85206-4609
US

IV. Provider business mailing address

4111 E VALLEY AUTO DR STE 201
MESA AZ
85206-4609
US

V. Phone/Fax

Practice location:
  • Phone: 480-818-5240
  • Fax:
Mailing address:
  • Phone: 480-818-5240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA HOOPS
Title or Position: OWNER
Credential: LCSW
Phone: 480-818-5240