=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316554678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND OVER MATTER MENTAL HEALTH, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2020
-----------------------------------------------------
Last Update Date | 09/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11011 S 48TH ST STE 200
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85044-1788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-471-0881
-----------------------------------------------------
Fax | 480-584-5497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4651 E LAVENDER LN
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85044-4815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-471-0881
-----------------------------------------------------
Fax | 480-584-5497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | DR. SALLY ANN ALEXANDER
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 602-471-0881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------