Provider Demographics
NPI:1053069294
Name:MAX BEHAVIORAL HEALTH OUTPATIENT
Entity Type:Organization
Organization Name:MAX BEHAVIORAL HEALTH OUTPATIENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:IRENE BASIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASEVERIYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:331-803-0822
Mailing Address - Street 1:12026 S 44TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-2432
Mailing Address - Country:US
Mailing Address - Phone:331-803-0822
Mailing Address - Fax:
Practice Address - Street 1:12026 S 44TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-2432
Practice Address - Country:US
Practice Address - Phone:331-803-0822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health