Provider Demographics
NPI:1427897438
Name:TESTIMONY BEHAVIORAL HEALTH RESIDENTIAL LLC
Entity type:Organization
Organization Name:TESTIMONY BEHAVIORAL HEALTH RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOJAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:FATOMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-383-3759
Mailing Address - Street 1:11770 W DAVIS LN
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7695
Mailing Address - Country:US
Mailing Address - Phone:623-383-3759
Mailing Address - Fax:
Practice Address - Street 1:1110 E GLENN DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5347
Practice Address - Country:US
Practice Address - Phone:623-383-3759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities