Provider Demographics
NPI:1588366959
Name:PHOENIX MIND BODY CONNECTION LLC
Entity type:Organization
Organization Name:PHOENIX MIND BODY CONNECTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:602-471-3124
Mailing Address - Street 1:PO BOX 16998
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:602-241-9580
Practice Address - Street 1:2942 N. 24TH ST SUITE 114
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-235-0575
Practice Address - Fax:602-241-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health