Healthcare Provider Details

I. General information

NPI: 1356158885
Provider Name (Legal Business Name): BE WISE WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 07/19/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5830 N 19TH AVE BLDG B
PHOENIX AZ
85015-2494
US

IV. Provider business mailing address

PO BOX 464
PEORIA AZ
85380-0464
US

V. Phone/Fax

Practice location:
  • Phone: 800-817-6437
  • Fax:
Mailing address:
  • Phone: 480-219-7785
  • Fax: 800-793-4656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRANDI CAUDELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-486-4328