Provider Demographics
NPI:1407257595
Name:MIKID MENTALLY ILL KIDS IN DISTRESS
Entity Type:Organization
Organization Name:MIKID MENTALLY ILL KIDS IN DISTRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GEASLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:602-253-1240
Mailing Address - Street 1:7816 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7036
Mailing Address - Country:US
Mailing Address - Phone:602-253-1240
Mailing Address - Fax:
Practice Address - Street 1:901 E COTTONWOOD LN STE AB
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2221
Practice Address - Country:US
Practice Address - Phone:520-509-6669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC8547251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health