Provider Demographics
NPI:1194413419
Name:WISTERIA MENTAL HEALTH & WELLNESS CENTER PLLC
Entity type:Organization
Organization Name:WISTERIA MENTAL HEALTH & WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:IGOR
Authorized Official - Last Name:BRACAMONTE VALENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-350-3046
Mailing Address - Street 1:14802 N 18TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3925
Mailing Address - Country:US
Mailing Address - Phone:480-399-8455
Mailing Address - Fax:866-845-1832
Practice Address - Street 1:301 W ECHO LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5554
Practice Address - Country:US
Practice Address - Phone:480-399-8455
Practice Address - Fax:866-845-1832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-25
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty