Provider Demographics
NPI:1477910883
Name:MERCIFUL BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:MERCIFUL BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OKUNLOLA
Authorized Official - Middle Name:O
Authorized Official - Last Name:BETIKU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-516-4992
Mailing Address - Street 1:12383 W GLENROSA AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-4287
Mailing Address - Country:US
Mailing Address - Phone:602-516-4992
Mailing Address - Fax:
Practice Address - Street 1:12383 W GLENROSA AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4287
Practice Address - Country:US
Practice Address - Phone:602-516-4992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4775320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH4775OtherBEHAVIORAL HEALTH