Healthcare Provider Details

I. General information

NPI: 1376209916
Provider Name (Legal Business Name): MY BEHAVIORAL HEALTH TREATMENT CENTER (MYBHTC)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19840 N CAVE CREEK RD
PHOENIX AZ
85024-1226
US

IV. Provider business mailing address

3039 W PEORIA AVE STE 102
PHOENIX AZ
85029-5212
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-6779
  • Fax: 312-610-5767
Mailing address:
  • Phone: 602-888-6779
  • Fax: 312-610-5767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROSALYN YOUNG
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-888-6779