Healthcare Provider Details

I. General information

NPI: 1780203794
Provider Name (Legal Business Name): CORNERSTONE HEALING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7655 E REDFIELD RD STE 4
SCOTTSDALE AZ
85260-6907
US

IV. Provider business mailing address

7655 E REDFIELD RD STE 4
SCOTTSDALE AZ
85260-6907
US

V. Phone/Fax

Practice location:
  • Phone: 800-480-1781
  • Fax: 612-326-0569
Mailing address:
  • Phone: 800-480-1781
  • Fax: 612-326-0569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ESTIL WALLACE
Title or Position: FOUNDER/CEO
Credential:
Phone: 602-544-6832