Provider Demographics
NPI:1003566845
Name:BLACK CANYON THERAPY AND WELLNESS
Entity Type:Organization
Organization Name:BLACK CANYON THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:585-339-8822
Mailing Address - Street 1:3061 W CASINO AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-5890
Mailing Address - Country:US
Mailing Address - Phone:585-339-8822
Mailing Address - Fax:
Practice Address - Street 1:3061 W CASINO AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-5890
Practice Address - Country:US
Practice Address - Phone:585-339-8822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty