MEDICARE: SOLACE WELLNESS MANAGEMENT SERVICE, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103K00000X	Behavior Analyst
2	101YM0800X	Mental Health Counselor
3	101YA0400X	Addiction (Substance Use Disorder) Counselor
4	103TA0400X	Addiction (Substance Use Disorder) Psychologist
5	103TB0200X	Cognitive & Behavioral Psychologist
6	103TR0400X	Rehabilitation Psychologist

General Provider Information

NPI Number	:	1912250119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOLACE WELLNESS MANAGEMENT SERVICE, LLC

Provider Business Mailing Address
First Line	:	4203 S 37TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-1813
Country	:	US
Telephone Number	:	480-704-4707
Fax Number	:

Provider Business Practice Location Address
First Line	:	4203 S 37TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-1813
Country	:	US
Telephone Number	:	480-704-4707
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. EZEKIEL JOHNSON SR.
Credential	:
Telephone Number	:	480-704-4707

Provider Enumeration Date	:	10/25/2012
Last Update Date	:	05/07/2015

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