Healthcare Provider Details

I. General information

NPI: 1639880917
Provider Name (Legal Business Name): AJ SOUTHWEST VENTURES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 S RURAL RD STE 112
TEMPE AZ
85282-5500
US

IV. Provider business mailing address

3920 S RURAL RD STE 112
TEMPE AZ
85282-5500
US

V. Phone/Fax

Practice location:
  • Phone: 480-674-9220
  • Fax: 674-480-9231
Mailing address:
  • Phone: 480-674-9220
  • Fax: 674-480-9231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLYSON FERNSTROM
Title or Position: OWNER
Credential: MSW
Phone: 602-502-3806