Healthcare Provider Details

I. General information

NPI: 1992318562
Provider Name (Legal Business Name): COGNITIVE TRANSFORMATIONZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2622 S 102ND LN
TOLLESON AZ
85353-5678
US

IV. Provider business mailing address

PO BOX 304
TOLLESON AZ
85353-0304
US

V. Phone/Fax

Practice location:
  • Phone: 480-414-5070
  • 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 State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA HERNANDEZ
Title or Position: MANAGING MEMBER
Credential:
Phone: 480-414-5070