Provider Demographics
NPI: | 1205415957 |
---|---|
Name: | BEYOND BLUE HEALTH SERVICES LLC |
Entity Type: | Organization |
Organization Name: | BEYOND BLUE HEALTH SERVICES LLC |
Other - Org Name: | BEYOND BLUE HEALTH SERVICES LLC |
Other - Org Type: | Former Legal Business Name |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KEONA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SCOTT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 702-689-8658 |
Mailing Address - Street 1: | 7550 N 19TH AVE STE 104 |
Mailing Address - Street 2: | |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85021-7982 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 602-946-4120 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 7550 N 19TH AVE STE 104 |
Practice Address - Street 2: | |
Practice Address - City: | PHOENIX |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85021-7982 |
Practice Address - Country: | US |
Practice Address - Phone: | 602-946-4120 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-04-07 |
Last Update Date: | 2022-05-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | ||
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 251B00000X | Agencies | Case Management | ||
No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | Group - Multi-Specialty | |
No | 251S00000X | Agencies | Community/Behavioral Health | ||
No | 252Y00000X | Agencies | Early Intervention Provider Agency | ||
No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
Yes | 261QR0401X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | |
No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | ||
No | 323P00000X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |