Provider Demographics
NPI:1427536770
Name:MULLIGAN'S MANOR, INC.
Entity Type:Organization
Organization Name:MULLIGAN'S MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:SAMAYOA
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:480-831-8727
Mailing Address - Street 1:4701 S LAKESHORE DR UNIT 1
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7169
Mailing Address - Country:US
Mailing Address - Phone:480-831-8721
Mailing Address - Fax:480-272-8708
Practice Address - Street 1:4701 S LAKESHORE DR UNIT 1
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7169
Practice Address - Country:US
Practice Address - Phone:480-831-8721
Practice Address - Fax:480-272-8708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ217581Medicaid