MEDICARE: HEART TO HEART BEHAVIORAL HEALTH GROUP HOME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1336602788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART TO HEART BEHAVIORAL HEALTH GROUP HOME, LLC

Provider Business Mailing Address
First Line	:	3555 N SAILBOAT LN
Second Line	:
City	:	AVONDALE
State	:	AZ
Zip	:	85392-3620
Country	:	US
Telephone Number	:	480-977-9457
Fax Number	:

Provider Business Practice Location Address
First Line	:	8535 W PALM LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-3902
Country	:	US
Telephone Number	:	480-977-9457
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	USMAN J BUNDU
Credential	:	RN, MSN/PH
Telephone Number	:	480-977-9457

Provider Enumeration Date	:	04/12/2019
Last Update Date	:	04/12/2019

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