Healthcare Provider Details

I. General information

NPI: 1083330682
Provider Name (Legal Business Name): MIND 247 PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 N 24TH STREET 2ND FLOOR
PHOENIX AZ
85008-1051
US

IV. Provider business mailing address

1465 N SCOTTSDALE RD STE 400
SCOTTSDALE AZ
85257-3634
US

V. Phone/Fax

Practice location:
  • Phone: 844-646-3247
  • Fax: 480-546-4048
Mailing address:
  • Phone: 844-084-7992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: AISHA LYNN DEPRIEST
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 844-646-3247