Healthcare Provider Details

I. General information

NPI: 1083326649
Provider Name (Legal Business Name): GLORIA'S HOUSE OF HEALING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 N PACEY RD
PHOENIX AZ
85037-6301
US

IV. Provider business mailing address

2022 N PACEY RD
PHOENIX AZ
85037-6301
US

V. Phone/Fax

Practice location:
  • Phone: 623-256-0021
  • Fax:
Mailing address:
  • Phone: 623-256-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DELIA CONSENTINO
Title or Position: CEO
Credential: LISAC
Phone: 623-256-0021