Provider Demographics
NPI:1093117384
Name:DESTINY BEHAVIORAL HEALTH RESIDENTIAL CARE LLC 2
Entity Type:Organization
Organization Name:DESTINY BEHAVIORAL HEALTH RESIDENTIAL CARE LLC 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FUNSO
Authorized Official - Middle Name:FEYI
Authorized Official - Last Name:OGUNLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-374-3377
Mailing Address - Street 1:8824 W PRESTON LN
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-6993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2911 S 87TH DR
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-8650
Practice Address - Country:US
Practice Address - Phone:623-435-6566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4488320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness