Healthcare Provider Details

I. General information

NPI: 1548959935
Provider Name (Legal Business Name): CHILDREN'S BRAIN ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 E MCDOWELL RD STE 301
PHOENIX AZ
85006-2609
US

IV. Provider business mailing address

PO BOX 97876
PHOENIX AZ
85060-7876
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-2234
  • Fax: 866-985-7247
Mailing address:
  • Phone: 602-222-2234
  • Fax: 866-985-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: BRENDAN P CASSIDY
Title or Position: PRACTICE OWNER
Credential:
Phone: 602-222-2234