Healthcare Provider Details

I. General information

NPI: 1063683100
Provider Name (Legal Business Name): GRACE BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 E MAGNOLIA ST
PHOENIX AZ
85034-6819
US

IV. Provider business mailing address

2336 E MAGNOLIA ST
PHOENIX AZ
85034-6819
US

V. Phone/Fax

Practice location:
  • Phone: 602-231-0102
  • Fax: 602-231-0015
Mailing address:
  • Phone: 602-231-0102
  • Fax: 602-231-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CYNTHIA CROSS
Title or Position: VICE PRESIDENT
Credential:
Phone: 602-231-0102