Provider Demographics
NPI:1851735369
Name:MENTALLY ILL KIDS IN DISTRESS
Entity type:Organization
Organization Name:MENTALLY ILL KIDS IN DISTRESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZMIERCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, MBA
Authorized Official - Phone:480-414-4879
Mailing Address - Street 1:7816 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7036
Mailing Address - Country:US
Mailing Address - Phone:602-253-1240
Mailing Address - Fax:
Practice Address - Street 1:2615 E BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3631
Practice Address - Country:US
Practice Address - Phone:602-253-1240
Practice Address - Fax:602-253-1250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7588251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health