Provider Demographics
NPI:1124603394
Name:DIRECTLY AFFECTED
Entity Type:Organization
Organization Name:DIRECTLY AFFECTED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-980-2116
Mailing Address - Street 1:2522 S TERRIPIN
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-4959
Mailing Address - Country:US
Mailing Address - Phone:614-980-2116
Mailing Address - Fax:
Practice Address - Street 1:2522 S TERRIPIN
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-4959
Practice Address - Country:US
Practice Address - Phone:614-980-2116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency