Healthcare Provider Details

I. General information

NPI: 1427536770
Provider Name (Legal Business Name): MULLIGAN'S MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 S LAKESHORE DR UNIT 1
TEMPE AZ
85282-7169
US

IV. Provider business mailing address

4701 S LAKESHORE DR UNIT 1
TEMPE AZ
85282-7169
US

V. Phone/Fax

Practice location:
  • Phone: 480-831-8721
  • Fax: 480-272-8708
Mailing address:
  • Phone: 480-831-8721
  • Fax: 480-272-8708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SAMAYOA DIAZ
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 480-831-8727