Provider Demographics
NPI:1760158554
Name:DAKOTA VALLEY HEALING, LLC
Entity Type:Organization
Organization Name:DAKOTA VALLEY HEALING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ULONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLD COYOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-565-4014
Mailing Address - Street 1:2680 S VAL VISTA DR STE 143
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1621
Mailing Address - Country:US
Mailing Address - Phone:602-565-4014
Mailing Address - Fax:
Practice Address - Street 1:2680 S VAL VISTA DR STE 143
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1621
Practice Address - Country:US
Practice Address - Phone:602-565-4014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1801252200Medicaid