Basic Information
| Provider Information | |||||||||
| NPI: | 1386388767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IRENIC THERAPEUTIC SERVICES, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9375 E SHEA BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772071144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9375 E SHEA BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772071144 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2022 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | BURTON | ||||||||
| AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | FOUNDER CEO | ||||||||
| AuthorizedOfficialTelephone: | 4804352424 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.