Provider Demographics
NPI:1073726162
Name:INDEPENDENCE COACHING, L.L.C.
Entity Type:Organization
Organization Name:INDEPENDENCE COACHING, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VERN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:602-524-0583
Mailing Address - Street 1:1345 E BUTLER DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3824
Mailing Address - Country:US
Mailing Address - Phone:602-524-0583
Mailing Address - Fax:602-297-6758
Practice Address - Street 1:1345 E BUTLER DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3824
Practice Address - Country:US
Practice Address - Phone:602-524-0583
Practice Address - Fax:602-297-6758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities