Provider Demographics
NPI:1275154585
Name:FREEDOM LOUNGE PLLC
Entity Type:Organization
Organization Name:FREEDOM LOUNGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WICKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-531-5973
Mailing Address - Street 1:209 E BASELINE RD STE E107
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1299
Mailing Address - Country:US
Mailing Address - Phone:480-531-5973
Mailing Address - Fax:480-542-8173
Practice Address - Street 1:209 E BASELINE RD STE E107
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1299
Practice Address - Country:US
Practice Address - Phone:480-531-5973
Practice Address - Fax:480-542-8173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty