Healthcare Provider Details

I. General information

NPI: 1033822804
Provider Name (Legal Business Name): FULL CIRCLE WELLNESS COLLECTIVE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2022
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 AIRWAY AVE STE F120
COSTA MESA CA
92626-4623
US

IV. Provider business mailing address

3151 AIRWAY AVE STE F120
COSTA MESA CA
92626-4623
US

V. Phone/Fax

Practice location:
  • Phone: 714-406-0454
  • Fax: 714-617-2934
Mailing address:
  • Phone: 714-406-0454
  • Fax: 714-617-2934

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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. SHAHRZAD AZARAFZA
Title or Position: PRESIDENT/FOUNDER & PSYCHOTHERAPIST
Credential: LCSW
Phone: 714-406-0454