Provider Demographics
NPI:1972838167
Name:STONEWALL INSTITUTE, LLC
Entity Type:Organization
Organization Name:STONEWALL INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:JAMISON
Authorized Official - Last Name:PENNIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LISAC
Authorized Official - Phone:602-535-6468
Mailing Address - Street 1:4020 N 20TH ST STE 302
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-6032
Mailing Address - Country:US
Mailing Address - Phone:602-535-6468
Mailing Address - Fax:
Practice Address - Street 1:4020 N 20TH ST STE 302
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6032
Practice Address - Country:US
Practice Address - Phone:602-535-6468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3856251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health