MEDICARE: GRACEVIEW BEHAVIORAL HEALTH 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1790427037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACEVIEW BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	3909 W WOOD DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-1952
Country	:	US
Telephone Number	:	480-206-8584
Fax Number	:	602-680-3323

Provider Business Practice Location Address
First Line	:	9531 S 16TH DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-5631
Country	:	US
Telephone Number	:	480-206-8584
Fax Number	:	602-680-3323

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	PATRICIA MUTHONI
Credential	:
Telephone Number	:	480-206-8584

Provider Enumeration Date	:	04/08/2022
Last Update Date	:	04/08/2022

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