MEDICARE: OPTIMUS BEHAVIORAL HEALTH 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1205507563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUS BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	4600 E WASHINGTON ST STE 300
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85034-1908
Country	:	US
Telephone Number	:	480-840-4777
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 E WASHINGTON ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85034-1903
Country	:	US
Telephone Number	:	480-840-4777
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. FLORA ISSANDA STOWATER
Credential	:	PSYCH NP
Telephone Number	:	480-840-4777

Provider Enumeration Date	:	09/25/2021
Last Update Date	:	12/06/2022

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