Provider Demographics
NPI:1982201299
Name:PROSPER AZ
Entity Type:Organization
Organization Name:PROSPER AZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-899-3015
Mailing Address - Street 1:10750 W MCDOWELL RD STE C301
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5964
Mailing Address - Country:US
Mailing Address - Phone:623-755-5679
Mailing Address - Fax:
Practice Address - Street 1:10750 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5960
Practice Address - Country:US
Practice Address - Phone:602-899-3015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health