Provider Demographics
NPI:1952003907
Name:ABK BEHAVIORAL HEALTH OUTPATIENT LLC
Entity type:Organization
Organization Name:ABK BEHAVIORAL HEALTH OUTPATIENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RWAGASANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-776-9334
Mailing Address - Street 1:9112 W FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-1513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4417 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2969
Practice Address - Country:US
Practice Address - Phone:033-180-3082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)