Provider Demographics
NPI:1588376297
Name:INTEGRATED BEHAVIORAL CARE & WELLNESS CENTER LLC
Entity type:Organization
Organization Name:INTEGRATED BEHAVIORAL CARE & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KENTA-BIBI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-518-1389
Mailing Address - Street 1:2266 S DOBSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6412
Mailing Address - Country:US
Mailing Address - Phone:860-518-1389
Mailing Address - Fax:
Practice Address - Street 1:2266 S DOBSON RD STE 200
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6412
Practice Address - Country:US
Practice Address - Phone:860-518-1389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC12102OtherAZDHS