Healthcare Provider Details

I. General information

NPI: 1588575815
Provider Name (Legal Business Name): EDIVAN MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2841 S JOSLYN
MESA AZ
85212-2176
US

IV. Provider business mailing address

2841 S JOSLYN
MESA AZ
85212-2176
US

V. Phone/Fax

Practice location:
  • Phone: 480-526-6115
  • Fax:
Mailing address:
  • Phone: 480-526-6115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IHEOMA AUGUSTINA SOROIBE
Title or Position: PMHNP
Credential: PMHNP
Phone: 480-526-6115