Healthcare Provider Details

I. General information

NPI: 1104459809
Provider Name (Legal Business Name): PRISM COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9299 W OLIVE AVE STE 212
PEORIA AZ
85345-8382
US

IV. Provider business mailing address

9299 W OLIVE AVE STE 212
PEORIA AZ
85345-8382
US

V. Phone/Fax

Practice location:
  • Phone: 480-525-7284
  • Fax:
Mailing address:
  • Phone: 480-525-7284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. TRES MANUEL ADAMES
Title or Position: DIRECTOR
Credential: MDIV, BCPC
Phone: 480-525-7284