Healthcare Provider Details

I. General information

NPI: 1790487353
Provider Name (Legal Business Name): MOMM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2822 N 32ND ST
PHOENIX AZ
85008-1261
US

IV. Provider business mailing address

2822 N 32ND ST
PHOENIX AZ
85008-1261
US

V. Phone/Fax

Practice location:
  • Phone: 602-803-2065
  • Fax:
Mailing address:
  • Phone: 602-803-2065
  • 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: JANOZZLE WRIGHT
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 602-803-2065