Provider Demographics
NPI:1285284539
Name:STAROAKS BEHAVIORAL HOME
Entity type:Organization
Organization Name:STAROAKS BEHAVIORAL HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINA
Authorized Official - Middle Name:O
Authorized Official - Last Name:JOEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-909-6953
Mailing Address - Street 1:1112 E IRMA LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-4118
Mailing Address - Country:US
Mailing Address - Phone:713-909-6953
Mailing Address - Fax:
Practice Address - Street 1:1112 E IRMA LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-4118
Practice Address - Country:US
Practice Address - Phone:713-909-6953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5894Medicaid