Provider Demographics
NPI:1578209920
Name:AZ LAVENDER BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:AZ LAVENDER BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ZUHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:FADL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-581-1588
Mailing Address - Street 1:3428 N 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-3101
Mailing Address - Country:US
Mailing Address - Phone:602-581-1588
Mailing Address - Fax:623-302-7174
Practice Address - Street 1:3428 N 47TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-3101
Practice Address - Country:US
Practice Address - Phone:602-581-1588
Practice Address - Fax:623-302-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH7476OtherDHS