=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396369310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY PSYCHIATRIC SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2020
-----------------------------------------------------
Last Update Date | 07/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14365 W GREER ST
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85379-4355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-278-4671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13954 W WADDELL RD STE 103-470
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85379-8750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-236-0084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER AND MANAGER
-----------------------------------------------------
Name | DARLENE MARIE HEIMMER
-----------------------------------------------------
Credential | MSN, APRN, PMHNP-BC
-----------------------------------------------------
Telephone | 631-278-3782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------