Healthcare Provider Details

I. General information

NPI: 1336800341
Provider Name (Legal Business Name): MENTALLY ILL KIDS IN DISTRESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E RIVERWALK UNIT 110
PUEBLO CO
81003-3308
US

IV. Provider business mailing address

7816 N 19TH AVE
PHOENIX AZ
85021-7036
US

V. Phone/Fax

Practice location:
  • Phone: 602-252-1240
  • Fax: 602-840-3409
Mailing address:
  • Phone: 602-253-1240
  • Fax: 602-840-3409

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEFF KAZMIERCZAK
Title or Position: CEO
Credential: RN,MSN,MBA
Phone: 602-253-1240