Healthcare Provider Details

I. General information

NPI: 1053710590
Provider Name (Legal Business Name): PREMIER HEALTH & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 N TATUM BLVD STE 128
PHOENIX AZ
85028-1620
US

IV. Provider business mailing address

11801 N TATUM BLVD STE 128
PHOENIX AZ
85028-1620
US

V. Phone/Fax

Practice location:
  • Phone: 602-795-9980
  • Fax:
Mailing address:
  • Phone: 602-388-1343
  • Fax: 602-795-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SONIA A GODBOLE
Title or Position: MEMBER
Credential: MD
Phone: 602-795-9980