Healthcare Provider Details

I. General information

NPI: 1396227609
Provider Name (Legal Business Name): PHOENIX MENTAL HEALTH AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3839 N 3RD ST STE 104
PHOENIX AZ
85012-2068
US

IV. Provider business mailing address

2450 S WHITE MOUNTAIN RD STE 3
SHOW LOW AZ
85901-7384
US

V. Phone/Fax

Practice location:
  • Phone: 928-985-1495
  • Fax:
Mailing address:
  • Phone: 928-985-1495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP11496
License Number StateAZ

VIII. Authorized Official

Name: STACY CLOYD
Title or Position: SECRETARY
Credential:
Phone: 763-330-4953