Provider Demographics
NPI:1043900335
Name:PHOENIX MENTAL HEALTH & WELLNESS, PLLC
Entity type:Organization
Organization Name:PHOENIX MENTAL HEALTH & WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CAMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:303-868-5436
Mailing Address - Street 1:11865 W TULANE DR
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:CO
Mailing Address - Zip Code:80465-1179
Mailing Address - Country:US
Mailing Address - Phone:303-868-5436
Mailing Address - Fax:
Practice Address - Street 1:5353 W DARTMOUTH AVE STE 400
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80227-5517
Practice Address - Country:US
Practice Address - Phone:303-868-5436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000213185Medicaid