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Organization
VIVIFY WELLNESS LLC
Active
Organization
VIVIFY WELLNESS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LAURA FONTAINE (OWNER)
(480) 987-6529
Entity
Organization
Contact information
Practice address
2345 S ALMA SCHOOL RD, SUITE 105, MESA, AZ 85210-4012
(480) 206-4753
Mailing address
18445 E PINE VALLEY DR, QUEEN CREEK, AZ 85142-3622
(480) 206-4753
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
10622
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10622
LICENSE
AZ
Enumeration date
12/14/2015
Last updated
12/14/2015
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