Healthcare Provider Details

I. General information

NPI: 1760146393
Provider Name (Legal Business Name): NEW JOURNEY RESIDENTIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8135 N 35TH AVE APT 2097
PHOENIX AZ
85051-5886
US

IV. Provider business mailing address

8135 N 35TH AVE APT 2097
PHOENIX AZ
85051-5886
US

V. Phone/Fax

Practice location:
  • Phone: 602-583-5714
  • Fax:
Mailing address:
  • Phone: 602-583-5714
  • 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 Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: KIARA GRAHAM
Title or Position: OWNER
Credential:
Phone: 602-583-5714