MEDICARE: HAVASU BEHAVIORAL HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1033764097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVASU BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	1695 MESQUITE AVE STE 216
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5688
Country	:	US
Telephone Number	:	928-453-0404
Fax Number	:	928-855-2778

Provider Business Practice Location Address
First Line	:	1695 MESQUITE AVE STE 216
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5688
Country	:	US
Telephone Number	:	928-453-0404
Fax Number	:

Authorized Official
Title or Position	:	LCSW
Name	:	KIMBERLY WALKER
Credential	:
Telephone Number	:	928-453-0404

Provider Enumeration Date	:	08/07/2019
Last Update Date	:	08/06/2025

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