Healthcare Provider Details

I. General information

NPI: 1609549922
Provider Name (Legal Business Name): MONTE VISTA BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6206 W MONTE VISTA RD
PHOENIX AZ
85035-3533
US

IV. Provider business mailing address

10720 W INDIAN SCHOOL RD STE 19
PHOENIX AZ
85037-5799
US

V. Phone/Fax

Practice location:
  • Phone: 28-886-7796
  • Fax: 312-610-5767
Mailing address:
  • Phone: 520-445-5832
  • Fax:

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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ANICET NDAGIJIMANA
Title or Position: CEO
Credential:
Phone: 520-445-5832