Provider Demographics
NPI:1609483825
Name:WISEMIND SOBER LIVING AND TREATMENT, LLC
Entity Type:Organization
Organization Name:WISEMIND SOBER LIVING AND TREATMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MCCREARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-265-7211
Mailing Address - Street 1:5755 W IRMA LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-9178
Mailing Address - Country:US
Mailing Address - Phone:563-265-7211
Mailing Address - Fax:
Practice Address - Street 1:6234 W BEHREND DR APT 3105
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6919
Practice Address - Country:US
Practice Address - Phone:480-665-5311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-30
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty