Provider Demographics
NPI:1972266757
Name:MENTAL HEALTH WELLNESS BOUTIQUE
Entity Type:Organization
Organization Name:MENTAL HEALTH WELLNESS BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHAMALLA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, FNP-C
Authorized Official - Phone:888-906-8301
Mailing Address - Street 1:10210 W HAPPY VALLEY PKWY STE 145
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2881
Mailing Address - Country:US
Mailing Address - Phone:888-906-8301
Mailing Address - Fax:623-404-6602
Practice Address - Street 1:10210 W HAPPY VALLEY PKWY STE 145
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2881
Practice Address - Country:US
Practice Address - Phone:888-906-8301
Practice Address - Fax:623-404-6602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1205365772OtherINDIVIDUAL NPI