Provider Demographics
NPI:1629533906
Name:THIRD EYE INTEGRATION, LLC
Entity Type:Organization
Organization Name:THIRD EYE INTEGRATION, LLC
Other - Org Name:THIRD EYE INTEGRATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCTP
Authorized Official - Phone:623-986-3987
Mailing Address - Street 1:18631 N 19TH AVE STE 158305
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-0408
Mailing Address - Country:US
Mailing Address - Phone:623-986-3987
Mailing Address - Fax:
Practice Address - Street 1:18631 N 19TH AVE STE 158305
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-0408
Practice Address - Country:US
Practice Address - Phone:623-986-3987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-31
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health