Provider Demographics
NPI:1891701280
Name:MIKID, MENTALLY ILL KIDS IN DISTRESS
Entity Type:Organization
Organization Name:MIKID, MENTALLY ILL KIDS IN DISTRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:602-253-1240
Mailing Address - Street 1:755 E WILLETTA ST
Mailing Address - Street 2:STE. 128
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2723
Mailing Address - Country:US
Mailing Address - Phone:602-253-1240
Mailing Address - Fax:602-253-1250
Practice Address - Street 1:755 E WILLETTA ST
Practice Address - Street 2:STE. 128
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2723
Practice Address - Country:US
Practice Address - Phone:602-253-1240
Practice Address - Fax:602-253-1250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSA05CP0172251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ895394Medicaid