Healthcare Provider Details

I. General information

NPI: 1386350049
Provider Name (Legal Business Name): MAKINI MENTAL HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11225 N 28TH DR STE D201
PHOENIX AZ
85029-5614
US

IV. Provider business mailing address

11225 N 28TH DR STE D201
PHOENIX AZ
85029-5614
US

V. Phone/Fax

Practice location:
  • Phone: 602-327-1854
  • Fax: 602-848-3654
Mailing address:
  • Phone: 602-327-1854
  • Fax: 602-848-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STANLEY KIDIAVAYI
Title or Position: PROVIDER
Credential: NP
Phone: 602-327-1854