MEDICARE: KALEIDOSCOPE COUNSELING & WELLNESS, PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1104598960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KALEIDOSCOPE COUNSELING & WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 17347
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85731-7347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5406 S BLACK FALLS DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85747-6087
Country	:	US
Telephone Number	:	520-222-6724
Fax Number	:

Authorized Official
Title or Position	:	PRIVATE PRACTICE OWNER / THERAPIST
Name	:	MICHELLE ROSENBALM
Credential	:
Telephone Number	:	520-222-6724

Provider Enumeration Date	:	09/30/2021
Last Update Date	:	09/30/2021

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