MEDICARE: HEART SONG WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1073171153	OTHER		NPI
2	1154445062	OTHER		NPI

General Provider Information

NPI Number	:	1073171153
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART SONG WELLNESS LLC

Provider Business Mailing Address
First Line	:	8715 W UNION HILLS DR STE 111
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-3031
Country	:	US
Telephone Number	:	425-233-1732
Fax Number	:	623-248-7737

Provider Business Practice Location Address
First Line	:	8715 W UNION HILLS DR STE 111
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-3031
Country	:	US
Telephone Number	:	425-233-1732
Fax Number	:	623-248-7737

Authorized Official
Title or Position	:	OWNER
Name	:	KARYN A MACKENZIE FAJARDO
Credential	:	LCSW
Telephone Number	:	425-233-1732

Provider Enumeration Date	:	06/03/2019
Last Update Date	:	03/07/2022

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