Healthcare Provider Details

I. General information

NPI: 1689131054
Provider Name (Legal Business Name): FAMILY TREE THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 E AGAVE RD STE 106
PHOENIX AZ
85044-0620
US

IV. Provider business mailing address

4425 E AGAVE RD STE 106
PHOENIX AZ
85044-0620
US

V. Phone/Fax

Practice location:
  • Phone: 480-248-5338
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DALISA JIMENEZ
Title or Position: OWNER
Credential: LPC
Phone: 954-253-8559