Healthcare Provider Details

I. General information

NPI: 1619033701
Provider Name (Legal Business Name): CHARLES CRAIG MILLS MC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2006
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 E CAMELBACK RD SUITE 230H
PHOENIX AZ
85018-2745
US

IV. Provider business mailing address

1261 W. LYNX WAY
CHANDLER AZ
85248
US

V. Phone/Fax

Practice location:
  • Phone: 602-852-0911
  • Fax: 602-852-0632
Mailing address:
  • Phone: 602-852-0911
  • Fax: 602-852-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-0245
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: