=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699094904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AAG SERENITY SERVIVES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2010
-----------------------------------------------------
Last Update Date | 07/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14708 W LUPINE LN
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-9688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-203-0696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14708 W LUPINE LN
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-9688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-203-0696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, MANAGER, CLINICAL DIRECTOR,
-----------------------------------------------------
Name | MRS. ALISON A GAMEZ
-----------------------------------------------------
Credential | MA, NCC, LPC
-----------------------------------------------------
Telephone | 623-203-0696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | N-15914236
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------