Provider Demographics
NPI:1396145694
Name:BARAKA HOUSE LLC
Entity type:Organization
Organization Name:BARAKA HOUSE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:OKORIE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PHD, LPC
Authorized Official - Phone:602-524-0824
Mailing Address - Street 1:10000 N 31ST AVE STE A107
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-9582
Mailing Address - Country:US
Mailing Address - Phone:602-524-0824
Mailing Address - Fax:800-881-7511
Practice Address - Street 1:3302 W MESCAL ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4114
Practice Address - Country:US
Practice Address - Phone:602-595-7871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-25
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4472320800000X
3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH4472OtherADHS