Provider Demographics
NPI:1104413863
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:CO OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SEKOU
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONZO
Authorized Official - Suffix:
Authorized Official - Credentials:MALIKEE SONIE
Authorized Official - Phone:216-630-9350
Mailing Address - Street 1:7346 N 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-1602
Mailing Address - Country:US
Mailing Address - Phone:216-630-9350
Mailing Address - Fax:
Practice Address - Street 1:7346 N 72ND AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-1602
Practice Address - Country:US
Practice Address - Phone:216-630-9350
Practice Address - Fax:602-581-3000
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health