Provider Demographics
NPI:1114536752
Name:THE HERITAGE BEHAVIORAL HEALTH HOME LLC
Entity Type:Organization
Organization Name:THE HERITAGE BEHAVIORAL HEALTH HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-270-4676
Mailing Address - Street 1:3927 W ROVEY AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-1633
Mailing Address - Country:US
Mailing Address - Phone:973-452-2505
Mailing Address - Fax:
Practice Address - Street 1:3927 W ROVEY AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-1633
Practice Address - Country:US
Practice Address - Phone:602-675-3975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ00000000Medicaid