Healthcare Provider Details

I. General information

NPI: 1790607208
Provider Name (Legal Business Name): MIRA PSYCHIATRY GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W SOUTHERN AVE STE 105
TEMPE AZ
85282-4500
US

IV. Provider business mailing address

22424 S ELLSWORTH LOOP RD UNIT 784
QUEEN CREEK AZ
85142-7107
US

V. Phone/Fax

Practice location:
  • Phone: 480-900-0965
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: THOMAS MATHEW
Title or Position: OWNER
Credential: FNP-C, PMHNP-C
Phone: 480-900-0965