Healthcare Provider Details

I. General information

NPI: 1740111053
Provider Name (Legal Business Name): ANYSSA ACEDO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15429 W CAMERON DR
SURPRISE AZ
85379-5205
US

IV. Provider business mailing address

15429 W CAMERON DR
SURPRISE AZ
85379-5205
US

V. Phone/Fax

Practice location:
  • Phone: 586-276-5562
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: