Provider Demographics
NPI:1407186737
Name:GRACE HOUSE BEHAVIORAL HEALTH AGENCY LEVEL 3
Entity Type:Organization
Organization Name:GRACE HOUSE BEHAVIORAL HEALTH AGENCY LEVEL 3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-583-8086
Mailing Address - Street 1:2733 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-1734
Mailing Address - Country:US
Mailing Address - Phone:623-583-8086
Mailing Address - Fax:
Practice Address - Street 1:2733 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-1734
Practice Address - Country:US
Practice Address - Phone:623-583-8086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3475320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness