MEDICARE: FOURTH WALL 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	101YM0800X	Mental Health Counselor
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1124869581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOURTH WALL WELLNESS LLC

Provider Business Mailing Address
First Line	:	6137 E GRANT RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-5829
Country	:	US
Telephone Number	:	520-436-3922
Fax Number	:

Provider Business Practice Location Address
First Line	:	6137 E GRANT RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-5829
Country	:	US
Telephone Number	:	520-436-3922
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	AURORA THRUSH
Credential	:	LPC
Telephone Number	:	720-232-7784

Provider Enumeration Date	:	06/01/2024
Last Update Date	:	02/24/2025

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Directions to “FOURTH WALL WELLNESS LLC ” Practice Location

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