Provider Demographics
NPI:1780008672
Name:MENTALLY ILL KIDS IN DISTRESS
Entity Type:Organization
Organization Name:MENTALLY ILL KIDS IN DISTRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZMIERCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:RN,MSN,MBA
Authorized Official - Phone:602-253-1240
Mailing Address - Street 1:7816 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7036
Mailing Address - Country:US
Mailing Address - Phone:602-253-1240
Mailing Address - Fax:
Practice Address - Street 1:2891 S PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-3512
Practice Address - Country:US
Practice Address - Phone:928-344-1983
Practice Address - Fax:928-493-3976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health