Provider Demographics
NPI:1942659990
Name:A BROAD JOURNEY INTERVENTION
Entity Type:Organization
Organization Name:A BROAD JOURNEY INTERVENTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MAED
Authorized Official - Phone:602-488-0135
Mailing Address - Street 1:6216 S 36TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-4904
Mailing Address - Country:US
Mailing Address - Phone:602-488-0135
Mailing Address - Fax:602-314-6073
Practice Address - Street 1:619 W BEAUTIFUL LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-8050
Practice Address - Country:US
Practice Address - Phone:602-488-0135
Practice Address - Fax:602-314-6073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency