Healthcare Provider Details

I. General information

NPI: 1124705587
Provider Name (Legal Business Name): WALLACE ANDREWS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W BELL RD STE 373
PHOENIX AZ
85023-3516
US

IV. Provider business mailing address

1453 N DYSART RD STE 322
AVONDALE AZ
85323-1539
US

V. Phone/Fax

Practice location:
  • Phone: 480-925-1393
  • Fax:
Mailing address:
  • Phone: 480-925-1393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. WALLACE CLYDE ANDREWS III
Title or Position: BHT/FACILITATOR/WELLNESS COACH
Credential: BEHAVIORAL HEALTH
Phone: 480-925-1393