Provider Demographics
NPI:1922275692
Name:MOHAVE MENTAL HEALTH CLINIC INC
Entity Type:Organization
Organization Name:MOHAVE MENTAL HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ABBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:928-757-8111
Mailing Address - Street 1:1743 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0927
Mailing Address - Country:US
Mailing Address - Phone:928-757-8111
Mailing Address - Fax:928-757-3256
Practice Address - Street 1:3505 WESTERN AVE STE A
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3074
Practice Address - Country:US
Practice Address - Phone:928-757-8111
Practice Address - Fax:928-757-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2398251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ138143Medicare PIN