Healthcare Provider Details

I. General information

NPI: 1164069167
Provider Name (Legal Business Name): RISING YOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 S SAWYER CIR
MESA AZ
85209-6256
US

IV. Provider business mailing address

501 S 48TH ST STE 110
TEMPE AZ
85281-2313
US

V. Phone/Fax

Practice location:
  • Phone: 480-232-8600
  • Fax: 480-444-1452
Mailing address:
  • Phone: 480-232-8600
  • Fax: 480-444-1452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KAYLA CHRISTINE SOL
Title or Position: ADMINISTRATOR
Credential:
Phone: 480-232-8600