Healthcare Provider Details

I. General information

NPI: 1104929504
Provider Name (Legal Business Name): PRISMA COMMUNITY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N. CENTRAL AVENUE SUITE 200
PHOENIX AZ
85004
US

IV. Provider business mailing address

1101 N CENTRAL AVE STE 200
PHOENIX AZ
85004-1844
US

V. Phone/Fax

Practice location:
  • Phone: 602-307-5330
  • Fax: 602-307-5021
Mailing address:
  • Phone: 602-347-0873
  • Fax: 602-246-1980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: CASEY SIMON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 602-307-5330