Provider Demographics
NPI:1295559441
Name:WANDERIST BEHAVIORAL HEALTH PLLC
Entity type:Organization
Organization Name:WANDERIST BEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PMHNP-BC
Authorized Official - Phone:626-515-8875
Mailing Address - Street 1:2600 E SOUTHERN AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7609
Mailing Address - Country:US
Mailing Address - Phone:626-515-8875
Mailing Address - Fax:
Practice Address - Street 1:2600 E SOUTHERN AVE STE C3
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7609
Practice Address - Country:US
Practice Address - Phone:626-515-8875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty