Healthcare Provider Details

I. General information

NPI: 1134850050
Provider Name (Legal Business Name): WERISE BEHAVIORAL HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10514 W HILTON AVE
TOLLESON AZ
85353-5615
US

IV. Provider business mailing address

1652 N 52ND ST APT 13
PHOENIX AZ
85008-3419
US

V. Phone/Fax

Practice location:
  • Phone: 612-987-4404
  • Fax:
Mailing address:
  • Phone: 480-324-6692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: IBRAHIM MOHAMUD HASSAN
Title or Position: AGENT
Credential:
Phone: 480-324-6692