Healthcare Provider Details

I. General information

NPI: 1427362201
Provider Name (Legal Business Name): MIDWEST BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 E INDIANA ST SUITE 103
EVANSVILLE IN
47715-2794
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 812-401-8008
  • Fax:
Mailing address:
  • Phone: 253-346-0392
  • Fax: 602-865-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20040842A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34000761A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02001874A
License Number StateIN

VIII. Authorized Official

Name: RYAN PARDO
Title or Position: CHIEF LEGAL OFFICER
Credential:
Phone: 206-399-1493