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General NPI Number Information
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NPI Number | 1770038564
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Entity Type | Organization
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Legal Business Name | SOUTH MOUNTAIN HOLISTIC CARE
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Dates
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Enumeration Date | 08/22/2016
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Last Update Date | 08/22/2016
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Provider Practice Location Address
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Address Line | 3219 W OLNEY AVE
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City | LAVEEN
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State | AZ
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Zip | 85339-1783
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Country | US
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Telephone | 602-565-5909
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Fax |
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Provider Business Mailing Address
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Address Line | 3219 W OLNEY AVE
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City | LAVEEN
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State | AZ
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Zip | 85339
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Country | US
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Telephone | 602-565-5909
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. STEPHANIE LYNN BRIGHAM
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Credential |
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Telephone | 602-565-5909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310500000X
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Taxonomy Name | Mental Illness Intermediate Care Facility
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License Number | BH4914
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License Number State | AZ
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