Healthcare Provider Details

I. General information

NPI: 1538958970
Provider Name (Legal Business Name): CROWN BEHAVIORAL INTEGRATED CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 09/28/2025
Certification Date: 09/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6619 N 19TH AVE STE C1
PHOENIX AZ
85015-1631
US

IV. Provider business mailing address

6619 N 19TH AVE STE C1
PHOENIX AZ
85015-1631
US

V. Phone/Fax

Practice location:
  • Phone: 480-214-5886
  • Fax:
Mailing address:
  • Phone: 480-214-5886
  • 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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MAURICE MBARUSHIMANA
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-312-1334