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General NPI Number Information
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NPI Number | 1609483825
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Entity Type | Organization
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Legal Business Name | WISEMIND SOBER LIVING AND TREATMENT, LLC
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Dates
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Enumeration Date | 09/30/2020
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Last Update Date | 11/10/2020
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Provider Practice Location Address
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Address Line | 6234 W BEHREND DR APT 3105
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City | GLENDALE
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State | AZ
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Zip | 85308-6919
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Country | US
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Telephone | 480-665-5311
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Fax |
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Provider Business Mailing Address
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Address Line | 5755 W IRMA LN
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City | GLENDALE
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State | AZ
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Zip | 85308-9178
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Country | US
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Telephone | 563-265-7211
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | JAMES DANIEL MCCREARY
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Credential |
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Telephone | 563-265-7211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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