Provider Demographics
NPI:1396914735
Name:TRI-PHASE GROUP HOME INC
Entity type:Organization
Organization Name:TRI-PHASE GROUP HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-474-6326
Mailing Address - Street 1:18403 W VERDIN RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5081
Mailing Address - Country:US
Mailing Address - Phone:623-474-6326
Mailing Address - Fax:623-474-6516
Practice Address - Street 1:1575 E BETSY LN UNIT D
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3759
Practice Address - Country:US
Practice Address - Phone:623-474-6326
Practice Address - Fax:623-474-6516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-19143245S0500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, ChildrenGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ873770OtherAHCCCS