Provider Demographics
NPI:1194312876
Name:FAITH BEHAVIORAL HEALTH GROUP, LLC
Entity type:Organization
Organization Name:FAITH BEHAVIORAL HEALTH GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIILU
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-441-9520
Mailing Address - Street 1:17870 W BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-2582
Mailing Address - Country:US
Mailing Address - Phone:623-600-8822
Mailing Address - Fax:623-600-8822
Practice Address - Street 1:17870 W BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-2582
Practice Address - Country:US
Practice Address - Phone:623-600-8822
Practice Address - Fax:623-600-8822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAITH BEHAVIORAL HEALTH GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-28
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness