Provider Demographics
NPI:1740967249
Name:HEAL VALLEY CLINIC LLC
Entity type:Organization
Organization Name:HEAL VALLEY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LANDRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KWIZERA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:857-264-7049
Mailing Address - Street 1:1737 E BASELINE RD
Mailing Address - Street 2:105
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233
Mailing Address - Country:US
Mailing Address - Phone:857-264-7049
Mailing Address - Fax:
Practice Address - Street 1:1737 E BASELINE RD
Practice Address - Street 2:105
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233
Practice Address - Country:US
Practice Address - Phone:857-264-7049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty