Provider Demographics
NPI:1447601448
Name:MATTIE'S CARE HOUSE, LLC
Entity Type:Organization
Organization Name:MATTIE'S CARE HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LATOYA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-686-0419
Mailing Address - Street 1:6823 W PLEASANT LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2660
Mailing Address - Country:US
Mailing Address - Phone:602-686-0419
Mailing Address - Fax:602-687-9742
Practice Address - Street 1:6823 W PLEASANT LN
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2660
Practice Address - Country:US
Practice Address - Phone:602-686-0419
Practice Address - Fax:602-687-9742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-30
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4867320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ148847OtherAHCCCS