Provider Demographics
NPI:1104495084
Name:IMMANUEL BEHAVIORAL HEALTH COUNSELING CLINIC
Entity type:Organization
Organization Name:IMMANUEL BEHAVIORAL HEALTH COUNSELING CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD MA
Authorized Official - Phone:623-738-8549
Mailing Address - Street 1:11301 N 99TH AVE STE 5120
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-5485
Mailing Address - Country:US
Mailing Address - Phone:623-876-6379
Mailing Address - Fax:623-876-6379
Practice Address - Street 1:11301 N 99TH AVE STE 5120
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-5485
Practice Address - Country:US
Practice Address - Phone:623-876-6379
Practice Address - Fax:623-876-6379
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:15856
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-23
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ447591Medicaid