Provider Demographics
NPI:1396227609
Name:PHOENIX MENTAL HEALTH AND WELLNESS PLLC
Entity Type:Organization
Organization Name:PHOENIX MENTAL HEALTH AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:COOPER
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-985-1495
Mailing Address - Street 1:5551 S WHITE MOUNTAIN RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7449
Mailing Address - Country:US
Mailing Address - Phone:928-985-1495
Mailing Address - Fax:928-597-5198
Practice Address - Street 1:914 N SAN FRANCISCO ST STE D
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3254
Practice Address - Country:US
Practice Address - Phone:928-985-1495
Practice Address - Fax:985-597-5198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11496363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty