Provider Demographics
NPI:1710438460
Name:STAROAKS BEHAVIORAL HOME
Entity Type:Organization
Organization Name:STAROAKS BEHAVIORAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINA
Authorized Official - Middle Name:OMOGHENE
Authorized Official - Last Name:JOEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-909-6953
Mailing Address - Street 1:1642 E CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6315
Mailing Address - Country:US
Mailing Address - Phone:713-909-6953
Mailing Address - Fax:
Practice Address - Street 1:1642 E CARDINAL DR
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6315
Practice Address - Country:US
Practice Address - Phone:713-909-6953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4920106S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH6749Medicaid