Healthcare Provider Details

I. General information

NPI: 1881990869
Provider Name (Legal Business Name): PERSONAL RECOVERY NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 01/18/2025
Certification Date: 01/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CORPORATE CENTER CT
STOCKBRIDGE GA
30281
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax: 770-389-3030
Mailing address:
  • Phone: 253-346-0392
  • Fax: 770-389-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN PARDO
Title or Position: LEGAL CHIEF OFFICER
Credential:
Phone: 206-399-1493