Healthcare Provider Details

I. General information

NPI: 1588366959
Provider Name (Legal Business Name): PHOENIX MIND BODY CONNECTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2942 N. 24TH ST SUITE 114
PHOENIX AZ
85016
US

IV. Provider business mailing address

PO BOX 16998
PHOENIX AZ
85011-6998
US

V. Phone/Fax

Practice location:
  • Phone: 602-235-0575
  • Fax: 602-241-9580
Mailing address:
  • Phone:
  • Fax: 602-241-9580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SHIRLEY D HANSON
Title or Position: CEO
Credential: LCSW
Phone: 602-471-3124