Provider Demographics
NPI:1992285852
Name:ACT MENTAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:ACT MENTAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:855-647-4228
Mailing Address - Street 1:2924 PONY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-8432
Mailing Address - Country:US
Mailing Address - Phone:507-380-7218
Mailing Address - Fax:
Practice Address - Street 1:30 ACOMA BLVD S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5957
Practice Address - Country:US
Practice Address - Phone:855-647-4228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty