Healthcare Provider Details

I. General information

NPI: 1427729342
Provider Name (Legal Business Name): JEREMY GWIZDALSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4657 S LAKESHORE DR STE 1
TEMPE AZ
85282-7170
US

IV. Provider business mailing address

1077 S ANNIE LN
GILBERT AZ
85296-1449
US

V. Phone/Fax

Practice location:
  • Phone: 480-718-1261
  • Fax:
Mailing address:
  • Phone: 623-216-6984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: