Healthcare Provider Details

I. General information

NPI: 1124603394
Provider Name (Legal Business Name): DIRECTLY AFFECTED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2522 S TERRIPIN
MESA AZ
85209-4959
US

IV. Provider business mailing address

2522 S TERRIPIN
MESA AZ
85209-4959
US

V. Phone/Fax

Practice location:
  • Phone: 614-980-2116
  • Fax:
Mailing address:
  • Phone: 614-980-2116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DOMINIQUE MYRICK
Title or Position: PRESIDENT
Credential:
Phone: 614-980-2116