Provider Demographics
NPI:1770883332
Name:MENTALLY ILL KIDS IN DISTRESS
Entity type:Organization
Organization Name:MENTALLY ILL KIDS IN DISTRESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZMIERCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:RN,MSN,MBA
Authorized Official - Phone:480-414-4879
Mailing Address - Street 1:7816 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7036
Mailing Address - Country:US
Mailing Address - Phone:480-414-4879
Mailing Address - Fax:602-253-1250
Practice Address - Street 1:810 GEMSTONE AVE STE 1&2&3
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6476
Practice Address - Country:US
Practice Address - Phone:928-733-0093
Practice Address - Fax:928-636-9904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAPPLICATION251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health