Provider Demographics
NPI:1417593575
Name:OBSIDIAN HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:OBSIDIAN HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-696-3556
Mailing Address - Street 1:13321 W INDIAN SCHOOL RD STE A107
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-4339
Mailing Address - Country:US
Mailing Address - Phone:623-293-2232
Mailing Address - Fax:623-321-9524
Practice Address - Street 1:13321 W INDIAN SCHOOL RD STE A107
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-4339
Practice Address - Country:US
Practice Address - Phone:623-293-2232
Practice Address - Fax:623-321-9524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ435346Medicaid