Healthcare Provider Details

I. General information

NPI: 1922920107
Provider Name (Legal Business Name): INNERVISION AZ, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2236 W BETHANY HOME RD # 421
PHOENIX AZ
85015-1934
US

IV. Provider business mailing address

2236 W BETHANY HOME RD # 421
PHOENIX AZ
85015-1934
US

V. Phone/Fax

Practice location:
  • Phone: 336-803-9598
  • Fax:
Mailing address:
  • Phone: 336-803-9598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: EBONY WIGGINS
Title or Position: PRESIDENT
Credential:
Phone: 336-803-9598