MEDICARE: FAITH IN YOURSELF BEHAVIORAL 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1629738901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAITH IN YOURSELF BEHAVIORAL LLC

Provider Business Mailing Address
First Line	:	2736 E WIER AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-2748
Country	:	US
Telephone Number	:	602-698-1758
Fax Number	:	602-671-6666

Provider Business Practice Location Address
First Line	:	2736 E WIER AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-2748
Country	:	US
Telephone Number	:	602-698-1758
Fax Number	:	602-671-6666

Authorized Official
Title or Position	:	STATUTORY OFFICER
Name	:	MR. IAN DY
Credential	:	NURSE PRACTITIONER
Telephone Number	:	480-280-8690

Provider Enumeration Date	:	12/28/2021
Last Update Date	:	12/28/2021

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