Healthcare Provider Details

I. General information

NPI: 1578294153
Provider Name (Legal Business Name): PINETOP BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/23/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 E WHITE MOUNTAIN BLVD # 5 BLVD 5
PINETOP AZ
85935
US

IV. Provider business mailing address

674 E WHITE MOUNTAIN BLVD # 5 BLVD 5
PINETOP AZ
85935
US

V. Phone/Fax

Practice location:
  • Phone: 207-409-6515
  • Fax:
Mailing address:
  • Phone:
  • 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

VIII. Authorized Official

Name: AIMEE NYIRAKANYANA
Title or Position: OWNER
Credential:
Phone: 207-409-6515