MEDICARE: PRATS RESIDENTIAL BEHAVIORAL HEALTH AGENCY IV

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	BH4111	AZ

General Provider Information

NPI Number	:	1730433137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRATS RESIDENTIAL BEHAVIORAL HEALTH AGENCY IV

Provider Business Mailing Address
First Line	:	3015 E GELDING DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032
Country	:	US
Telephone Number	:	602-400-2288
Fax Number	:

Provider Business Practice Location Address
First Line	:	13811 N 38TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-5713
Country	:	US
Telephone Number	:	602-348-2115
Fax Number	:	602-996-1577

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. GISELIA PRATS
Credential	:	LPC
Telephone Number	:	602-348-2115

Provider Enumeration Date	:	11/07/2012
Last Update Date	:	11/07/2012

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