=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104495084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMMANUEL BEHAVIORAL HEALTH COUNSELING CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2021
-----------------------------------------------------
Last Update Date | 04/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11301 N 99TH AVE STE 5120
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85345-5485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-876-6379
-----------------------------------------------------
Fax | 623-876-6379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11301 N 99TH AVE STE 5120
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85345-5485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-876-6379
-----------------------------------------------------
Fax | 623-876-6379
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | BRENDA KAY PIERCE
-----------------------------------------------------
Credential | MD MA
-----------------------------------------------------
Telephone | 623-738-8549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------