Healthcare Provider Details

I. General information

NPI: 1568235224
Provider Name (Legal Business Name): BRAVE HEARTS WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 N CENTRAL AVE
PHOENIX AZ
85020-2430
US

IV. Provider business mailing address

31 E THOMAS RD APT 446
PHOENIX AZ
85012-0056
US

V. Phone/Fax

Practice location:
  • Phone: 623-244-7403
  • Fax: 888-261-8990
Mailing address:
  • Phone: 480-664-4641
  • Fax: 888-261-8990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELSIE KALULE
Title or Position: OWNER
Credential:
Phone: 818-723-7338