Healthcare Provider Details

I. General information

NPI: 1528768587
Provider Name (Legal Business Name): SUNRISE MOUNTAIN BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17733 W CASSIA WAY
GOODYEAR AZ
85338-6430
US

IV. Provider business mailing address

17733 W CASSIA WAY
GOODYEAR AZ
85338-6430
US

V. Phone/Fax

Practice location:
  • Phone: 480-233-2544
  • Fax:
Mailing address:
  • Phone: 480-233-2544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
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: DR. ALINE INDATWA
Title or Position: ADMINISTRATOR
Credential: DR
Phone: 480-233-2544