Provider Demographics
NPI:1124649777
Name:DIVINE CHANGING HANDS
Entity type:Organization
Organization Name:DIVINE CHANGING HANDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIRSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-773-2872
Mailing Address - Street 1:1550 E MCKELLIPS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-2753
Mailing Address - Country:US
Mailing Address - Phone:480-597-4951
Mailing Address - Fax:480-597-3689
Practice Address - Street 1:1550 E MCKELLIPS RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2753
Practice Address - Country:US
Practice Address - Phone:480-597-4951
Practice Address - Fax:480-597-3689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080174Medicaid