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General NPI Number Information
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NPI Number | 1417593575
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Entity Type | Organization
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Legal Business Name | OBSIDIAN HEALTH AND WELLNESS LLC
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Dates
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Enumeration Date | 11/25/2019
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Last Update Date | 11/25/2019
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Provider Practice Location Address
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Address Line | 13321 W INDIAN SCHOOL RD STE A107
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City | LITCHFIELD PARK
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State | AZ
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Zip | 85340-4339
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Country | US
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Telephone | 623-293-2232
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Fax | 623-321-9524
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Provider Business Mailing Address
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Address Line | 13321 W INDIAN SCHOOL RD STE A107
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City | LITCHFIELD PARK
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State | AZ
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Zip | 85340-4339
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Country | US
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Telephone | 623-293-2232
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Fax | 623-321-9524
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Authorized Official
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Title or Position | CONSULTANT
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Name | DEBORAH GRACE
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Credential |
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Telephone | 602-696-3556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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