Provider Demographics
NPI:1891043311
Name:EAST VALLEY MENTAL WELLNESS PLLC
Entity Type:Organization
Organization Name:EAST VALLEY MENTAL WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANN MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASEY
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:480-570-0497
Mailing Address - Street 1:1166 E WARNER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3064
Mailing Address - Country:US
Mailing Address - Phone:480-570-0497
Mailing Address - Fax:480-452-0145
Practice Address - Street 1:1166 E WARNER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3064
Practice Address - Country:US
Practice Address - Phone:480-570-0497
Practice Address - Fax:480-452-0145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4476363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ726497Medicaid
AZZ93196Medicare PIN