MEDICARE: AZ PURE WELLNESS, LICENSED CLINICAL SOCIAL WORKER, P.C.

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

General Provider Information

NPI Number	:	1952032328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZ PURE WELLNESS, LICENSED CLINICAL SOCIAL WORKER, P.C.

Provider Business Mailing Address
First Line	:	7865 W BELL RD # 1056
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-3803
Country	:	US
Telephone Number	:	602-825-3925
Fax Number	:

Provider Business Practice Location Address
First Line	:	7865 W BELL RD # 1056
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-3803
Country	:	US
Telephone Number	:	602-825-3925
Fax Number	:

Authorized Official
Title or Position	:	CLINICIAN MANAGER
Name	:	VIVIAN FAJARDO
Credential	:	LCSW
Telephone Number	:	602-825-3925

Provider Enumeration Date	:	06/17/2022
Last Update Date	:	03/17/2025

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