MEDICARE: LATEEF BEHAVIORAL CARE HOME

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	3990	AZ

General Provider Information

NPI Number	:	1316218753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LATEEF BEHAVIORAL CARE HOME

Provider Business Mailing Address
First Line	:	8613 S 7TH DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-8311
Country	:	US
Telephone Number	:	602-314-5903
Fax Number	:

Provider Business Practice Location Address
First Line	:	8613 S 7TH DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-8311
Country	:	US
Telephone Number	:	602-314-5903
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MARYAM LATEEF
Credential	:	LPN
Telephone Number	:	602-403-5050

Provider Enumeration Date	:	01/17/2012
Last Update Date	:	01/17/2012

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