NPIMap

Organization Active NPI

Wisteria Mental Health & Wellness Center PLLC

  • Child & Adolescent Psychiatry Physician
  • Phoenix, AZ
National Provider Identifier
1194413419
Registry record updated Mar 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Child & Adolescent Psychiatry PhysicianTaxonomy code 2084P0804X
Legal business name
WISTERIA MENTAL HEALTH & WELLNESS CENTER PLLC
Practice address
301 W Echo LN
Phoenix, AZ 85021-5554
Phone
(480) 399-8455
Fax
(866) 845-1832
NPI assigned
Apr 25, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 14, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Roberto Igor Bracamonte Valencia, MDNPI 1205065299
Title
Ceo
Phone
(602) 350-3046

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Child & Adolescent Psychiatry PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2084P0804X Primary

Addresses

Primary practice location

301 W Echo LN
Phoenix, AZ 85021-5554

Mailing address

14802 N 18TH PL
Phoenix, AZ 85022-3925
Phone (480) 399-8455

National Provider Directory

National Provider Directory

Locations

77 E Thomas Rd
Ste 215
Phoenix, AZ 85012
Phone (480) 399-8455

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1682380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1741910400000",
    "number": "1194413419",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14802 N 18TH PL",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850223925",
            "telephone_number": "480-399-8455",
            "fax_number": "866-845-1832"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 W ECHO LN",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850215554",
            "telephone_number": "480-399-8455",
            "fax_number": "866-845-1832"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WISTERIA MENTAL HEALTH & WELLNESS CENTER PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-04-25",
        "last_updated": "2025-03-14",
        "certification_date": "2025-03-14",
        "status": "A",
        "authorized_official_last_name": "BRACAMONTE VALENCIA",
        "authorized_official_first_name": "ROBERTO",
        "authorized_official_middle_name": "IGOR",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "602-350-3046",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2084P0804X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Phoenix, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 14, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.