Provider Demographics
NPI:1922570878
Name:IMAGINE THERAPY PLLC
Entity Type:Organization
Organization Name:IMAGINE THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PLUM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:623-337-2275
Mailing Address - Street 1:PO BOX 7405
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-0641
Mailing Address - Country:US
Mailing Address - Phone:623-337-2275
Mailing Address - Fax:
Practice Address - Street 1:15655 W ROOSEVELT ST STE 202
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9306
Practice Address - Country:US
Practice Address - Phone:623-337-2275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ362794Medicaid