Provider Demographics
NPI:1912458589
Name:MOHAVE MENTAL HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:MOHAVE MENTAL HEALTH CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ABBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:928-757-8111
Mailing Address - Street 1:3707 N STOCKTON HILL RD STE B
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0507
Mailing Address - Country:US
Mailing Address - Phone:928-757-8111
Mailing Address - Fax:928-757-3256
Practice Address - Street 1:151 RIVIERA DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5740
Practice Address - Country:US
Practice Address - Phone:928-855-3432
Practice Address - Fax:928-855-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5021261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5021OtherADHS