=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619682440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRISM PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2023
-----------------------------------------------------
Last Update Date | 07/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4742 N 24TH ST STE 300
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-9107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-848-1935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4742 N 24TH ST STE 300
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-9107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-848-1935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | ABBAS GHAZI
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 480-848-1935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------