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General NPI Number Information
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NPI Number | 1427536770
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Entity Type | Organization
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Legal Business Name | MULLIGAN'S MANOR, INC.
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Dates
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Enumeration Date | 07/30/2018
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Last Update Date | 07/30/2018
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Provider Practice Location Address
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Address Line | 4701 S LAKESHORE DR UNIT 1
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City | TEMPE
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State | AZ
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Zip | 85282-7169
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Country | US
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Telephone | 480-831-8721
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Fax | 480-272-8708
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Provider Business Mailing Address
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Address Line | 4701 S LAKESHORE DR UNIT 1
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City | TEMPE
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State | AZ
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Zip | 85282-7169
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Country | US
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Telephone | 480-831-8721
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Fax | 480-272-8708
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JENNIFER SAMAYOA DIAZ
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Credential | LCSW
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Telephone | 480-831-8727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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