Provider Demographics
NPI:1982150876
Name:MENTALLY ILL KIDS IN DISTRESS
Entity Type:Organization
Organization Name:MENTALLY ILL KIDS IN DISTRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF PROGRAMS
Authorized Official - Prefix:
Authorized Official - First Name:AKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:COMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:602-253-1240
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:602-253-1240
Mailing Address - Fax:602-840-3409
Practice Address - Street 1:1777 N FRANK REED RD
Practice Address - Street 2:SUITE 1 & 2
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-4031
Practice Address - Country:US
Practice Address - Phone:602-253-1240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7759251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health