=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457051948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPSUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2023
-----------------------------------------------------
Last Update Date | 10/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3458 E SOUTHERN AVE STE 103
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85204-5681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-569-3377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3458 E SOUTHERN AVE STE 103
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85204-5681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-569-3377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. OLUKEMI AKINBUSUYI
-----------------------------------------------------
Credential | MA
-----------------------------------------------------
Telephone | 480-569-3377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0807X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------