Provider Demographics
NPI:1285459149
Name:GREAT VALLEY BEHAVIORAL HOMES
Entity type:Organization
Organization Name:GREAT VALLEY BEHAVIORAL HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHOLLETA
Authorized Official - Middle Name:WANJIRU
Authorized Official - Last Name:MENJA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP,PMHNP-BC
Authorized Official - Phone:480-232-8260
Mailing Address - Street 1:5723 W PUEBLO AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-6404
Mailing Address - Country:US
Mailing Address - Phone:480-232-8260
Mailing Address - Fax:
Practice Address - Street 1:5610 W HARDTACK TRL
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-1276
Practice Address - Country:US
Practice Address - Phone:480-232-8260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT VALLEY BEHAVIORAL HOMES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-16
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility