Healthcare Provider Details

I. General information

NPI: 1215574496
Provider Name (Legal Business Name): OLIVE BRANCH BEHAVIORAL RESIDENCIAL NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2421 E ROBERT E LEE ST
PHOENIX AZ
85032-1082
US

IV. Provider business mailing address

15712 W EUCALYPTUS CT
SURPRISE AZ
85374-3308
US

V. Phone/Fax

Practice location:
  • Phone: 602-569-0806
  • Fax: 602-569-0537
Mailing address:
  • Phone: 708-277-8673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. TRACY BARSHELL KETCHUM
Title or Position: CAO,ADMINISTRATOR
Credential:
Phone: 708-277-8673