Healthcare Provider Details

I. General information

NPI: 1013244813
Provider Name (Legal Business Name): GLENEAGLE MENTAL HEALTH AGENCIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20348 E WARNER RD
MESA AZ
85212-9655
US

IV. Provider business mailing address

20348 E WARNER RD
MESA AZ
85212-9655
US

V. Phone/Fax

Practice location:
  • Phone: 480-988-9929
  • Fax: 480-279-3828
Mailing address:
  • Phone: 480-988-9929
  • Fax: 480-279-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License NumberBH 3402
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH 3402
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH 3402
License Number StateAZ

VIII. Authorized Official

Name: EVELYN WILLIAMS
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 480-988-9929