Provider Demographics
NPI:1154089696
Name:VIVIDLY VITALITY MENTORING & COUNSEL, LLC
Entity Type:Organization
Organization Name:VIVIDLY VITALITY MENTORING & COUNSEL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TALENCIA
Authorized Official - Middle Name:ARLICIA
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:480-484-8647
Mailing Address - Street 1:920 S TERRACE RD UNIT 5035
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-3805
Mailing Address - Country:US
Mailing Address - Phone:480-482-8647
Mailing Address - Fax:480-936-0000
Practice Address - Street 1:920 S TERRACE RD UNIT 5035
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-3805
Practice Address - Country:US
Practice Address - Phone:480-482-8647
Practice Address - Fax:480-936-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty