Provider Demographics
NPI:1801395876
Name:FAITH BEHAVIORAL HEALTH GROUP, LLC
Entity type:Organization
Organization Name:FAITH BEHAVIORAL HEALTH GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIILU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-441-9520
Mailing Address - Street 1:3101 W LARKSPUR DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-2331
Mailing Address - Country:US
Mailing Address - Phone:602-368-7178
Mailing Address - Fax:
Practice Address - Street 1:3101 W LARKSPUR DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-2331
Practice Address - Country:US
Practice Address - Phone:602-368-7178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5359320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5359OtherARIZONA STATE LICENSE