Healthcare Provider Details

I. General information

NPI: 1053180521
Provider Name (Legal Business Name): HEALED PHOENIX COUNSELING AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 W GLENDALE AVE STE A201
PHOENIX AZ
85051-8194
US

IV. Provider business mailing address

12317 W DENTON AVE
LITCHFIELD PARK AZ
85340-3434
US

V. Phone/Fax

Practice location:
  • Phone: 623-258-1904
  • Fax:
Mailing address:
  • Phone: 623-258-1904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TIFFANY BRYANT
Title or Position: PROVIDER/OWNER
Credential: LPC
Phone: 513-252-6939