Healthcare Provider Details

I. General information

NPI: 1891209961
Provider Name (Legal Business Name): DANTIA WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34406 N 27TH DR STE 140
PHOENIX AZ
85085-6079
US

IV. Provider business mailing address

PO BOX 43527
PHOENIX AZ
85080-3527
US

V. Phone/Fax

Practice location:
  • Phone: 602-859-5550
  • Fax:
Mailing address:
  • Phone: 602-859-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-16029
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-15223
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRA J HOUSE
Title or Position: AUTHORIZED OFFICIAL
Credential: MA, LPC
Phone: 602-859-5550