Healthcare Provider Details

I. General information

NPI: 1942073101
Provider Name (Legal Business Name): PREMIUM BEHAVIOR CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5251 W CAMPBELL AVE STE 203
PHOENIX AZ
85031-1719
US

IV. Provider business mailing address

5251 W CAMPBELL AVE STE 203
PHOENIX AZ
85031-1719
US

V. Phone/Fax

Practice location:
  • Phone: 602-486-4328
  • Fax:
Mailing address:
  • Phone: 480-258-8703
  • Fax:

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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DROCELLE WILSON
Title or Position: CEO
Credential:
Phone: 480-258-8703