=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356147128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTRY HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2025
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4444 N 25TH ST UNIT 43
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-5645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-363-2743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 11077
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85284-0018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-363-2743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KENNETH SEAN COUNTRYMAN
-----------------------------------------------------
Credential | JD
-----------------------------------------------------
Telephone | 602-363-2743
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------