Provider Demographics
NPI:1700527637
Name:PROVIDENCE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:PROVIDENCE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FUNMILOLA
Authorized Official - Middle Name:ELIZABETH-TOSIN
Authorized Official - Last Name:OGUNLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-628-2266
Mailing Address - Street 1:8714 W PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-8618
Mailing Address - Country:US
Mailing Address - Phone:602-628-2266
Mailing Address - Fax:
Practice Address - Street 1:8714 W PIONEER ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-8618
Practice Address - Country:US
Practice Address - Phone:602-628-2266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness