Healthcare Provider Details

I. General information

NPI: 1356137426
Provider Name (Legal Business Name): KOU BEHAVORIAL HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19752 W BUCHANAN ST
BUCKEYE AZ
85326-3054
US

IV. Provider business mailing address

19752 W BUCHANAN ST
BUCKEYE AZ
85326-3054
US

V. Phone/Fax

Practice location:
  • Phone: 480-203-2718
  • Fax:
Mailing address:
  • Phone: 480-203-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: WORTEE YALLAY
Title or Position: CEO
Credential:
Phone: 609-222-0263