Healthcare Provider Details

I. General information

NPI: 1710559513
Provider Name (Legal Business Name): MIND SPA SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1934 E CAMELBACK RD STE 210
PHOENIX AZ
85016
US

IV. Provider business mailing address

1934 E CAMELBACK RD STE 210
PHOENIX AZ
85016
US

V. Phone/Fax

Practice location:
  • Phone: 559-930-3459
  • Fax: 619-795-3274
Mailing address:
  • Phone: 559-930-3459
  • Fax: 619-795-3274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: FREDERICK DONALD MURRAY JR.
Title or Position: CEO
Credential:
Phone: 559-930-3459