=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336918119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANQUILITY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2023
-----------------------------------------------------
Last Update Date | 12/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 627 S 48TH ST STE 100
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-2353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-490-7837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14630 N 32ND LN
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85053-4704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-490-7837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. COURTNEY CHETTLE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 480-490-7837
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------