Healthcare Provider Details

I. General information

NPI: 1396145694
Provider Name (Legal Business Name): BARAKA HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2014
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 W MESCAL ST
PHOENIX AZ
85029-4114
US

IV. Provider business mailing address

10000 N 31ST AVE STE A107
PHOENIX AZ
85051-9582
US

V. Phone/Fax

Practice location:
  • Phone: 602-595-7871
  • Fax:
Mailing address:
  • Phone: 602-524-0824
  • Fax: 800-881-7511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH4472
License Number StateAZ

VIII. Authorized Official

Name: VICTOR OKORIE
Title or Position: OWNER/DIRECTOR
Credential: M.A., PH.D., LPC
Phone: 602-524-0824