Provider Demographics
NPI:1821632126
Name:MENTAL HEALTH AZFORVETS LLC
Entity Type:Organization
Organization Name:MENTAL HEALTH AZFORVETS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VARONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-260-9643
Mailing Address - Street 1:20469 N 95TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5133
Mailing Address - Country:US
Mailing Address - Phone:248-821-8587
Mailing Address - Fax:855-300-5330
Practice Address - Street 1:20469 N 95TH DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5133
Practice Address - Country:US
Practice Address - Phone:248-821-8587
Practice Address - Fax:855-300-5330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ161359Medicaid