Healthcare Provider Details

I. General information

NPI: 1467399972
Provider Name (Legal Business Name): GRACEWELL BEHAVIORAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W NORTHERN AVE STE 107
PHOENIX AZ
85021-5400
US

IV. Provider business mailing address

1717 W NORTHERN AVE STE 107
PHOENIX AZ
85021-5400
US

V. Phone/Fax

Practice location:
  • Phone: 781-985-1314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GRACE NASSANGA
Title or Position: DIRECTOR
Credential:
Phone: 781-985-1314