Healthcare Provider Details

I. General information

NPI: 1871227173
Provider Name (Legal Business Name): 123 SERENITY THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 E WASHINGTON ST STE 300
PHOENIX AZ
85034-1908
US

IV. Provider business mailing address

333 MEADOWOOD RD
JACKSON NJ
08527-1182
US

V. Phone/Fax

Practice location:
  • Phone: 845-418-5336
  • Fax:
Mailing address:
  • Phone: 347-946-9817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LEAH PESACH
Title or Position: PRESIDENT
Credential:
Phone: 347-946-9817