Provider Demographics
NPI:1497032668
Name:VISION GROUP HOME
Entity Type:Organization
Organization Name:VISION GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KETURAH
Authorized Official - Middle Name:MATTOX
Authorized Official - Last Name:SHARPE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, M ED, MA
Authorized Official - Phone:623-308-5414
Mailing Address - Street 1:2917 W BOWKER ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-3477
Mailing Address - Country:US
Mailing Address - Phone:623-308-5414
Mailing Address - Fax:602-305-8619
Practice Address - Street 1:2917 W BOWKER ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-3477
Practice Address - Country:US
Practice Address - Phone:623-308-5414
Practice Address - Fax:602-305-8619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3356322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children