MEDICARE: T&H BEHAVIORAL HEALTH AGENCY 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1205766631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	T&H BEHAVIORAL HEALTH AGENCY LLC

Provider Business Mailing Address
First Line	:	1809 E GWEN ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-8012
Country	:	US
Telephone Number	:	773-600-4302
Fax Number	:

Provider Business Practice Location Address
First Line	:	1809 E GWEN ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-8012
Country	:	US
Telephone Number	:	773-600-4302
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TALMADGE EDDIE WATTS-PORTER
Credential	:
Telephone Number	:	773-600-4302

Provider Enumeration Date	:	05/19/2026
Last Update Date	:	05/19/2026

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