Provider Demographics
NPI:1063974533
Name:STARGATE BEHAVIORAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:STARGATE BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SEKOU
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-630-9350
Mailing Address - Street 1:1924 W ALTA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5443
Mailing Address - Country:US
Mailing Address - Phone:901-652-8154
Mailing Address - Fax:
Practice Address - Street 1:1924 W ALTA VISTA RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5443
Practice Address - Country:US
Practice Address - Phone:901-652-8154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health