Provider Demographics
NPI:1215574496
Name:OLIVE BRANCH BEHAVIORAL RESIDENCIAL NETWORK, LLC
Entity Type:Organization
Organization Name:OLIVE BRANCH BEHAVIORAL RESIDENCIAL NETWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CAO,ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:BARSHELL
Authorized Official - Last Name:KETCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-277-8673
Mailing Address - Street 1:15712 W EUCALYPTUS CT
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-3308
Mailing Address - Country:US
Mailing Address - Phone:708-277-8673
Mailing Address - Fax:
Practice Address - Street 1:2421 E ROBERT E LEE ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-1082
Practice Address - Country:US
Practice Address - Phone:602-569-0806
Practice Address - Fax:602-569-0537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1028196670OtherBEHAVIORAL HEALTH