Healthcare Provider Details

I. General information

NPI: 1124758214
Provider Name (Legal Business Name): THE HERITAGE BEHAVIORAL HEALTH HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3927 W ROVEY AVE
PHOENIX AZ
85019-1633
US

IV. Provider business mailing address

3927 W ROVEY AVE
PHOENIX AZ
85019-1633
US

V. Phone/Fax

Practice location:
  • Phone: 973-452-2505
  • Fax:
Mailing address:
  • Phone: 973-452-2505
  • 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 Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: JULIA SMITH-DORSEY
Title or Position: CEO
Credential:
Phone: 973-452-2505