Healthcare Provider Details

I. General information

NPI: 1912250119
Provider Name (Legal Business Name): SOLACE WELLNESS MANAGEMENT SERVICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4203 S 37TH ST
PHOENIX AZ
85040-1813
US

IV. Provider business mailing address

4203 S 37TH ST
PHOENIX AZ
85040-1813
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-4707
  • Fax:
Mailing address:
  • Phone: 480-704-4707
  • 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 Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. EZEKIEL JOHNSON SR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 480-704-4707