=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801325493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE NEURO WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2017
-----------------------------------------------------
Last Update Date | 06/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 E MONTEREY WAY
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-2619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-292-6664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9138 W CLARA LN
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85382-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-292-6664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ERIN R. HONKE
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 480-292-6664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 4383
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 4383
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------