=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104413863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STARGATE BEHAVIORAL HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2020
-----------------------------------------------------
Last Update Date | 12/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7346 N 72ND AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85303-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-630-9350
-----------------------------------------------------
Fax | 602-581-3000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7346 N 72ND AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85303-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-630-9350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | SEKOU A DONZO
-----------------------------------------------------
Credential | MALIKEE SONIE
-----------------------------------------------------
Telephone | 216-630-9350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------