Healthcare Provider Details

I. General information

NPI: 1861226342
Provider Name (Legal Business Name): CLEARFIRE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 W PARKSIDE LN
PHOENIX AZ
85027-1228
US

IV. Provider business mailing address

13353 W LARIAT LN
PEORIA AZ
85383-5973
US

V. Phone/Fax

Practice location:
  • Phone: 480-757-5885
  • Fax:
Mailing address:
  • Phone: 480-757-5885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MICAELA WAMBOLDT
Title or Position: LPC
Credential:
Phone: 480-757-5885