MEDICARE: MENTALLY ILL KIDS IN DISTRESS

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	251S00000X	Community/Behavioral Health Agency	APPLICATION	AZ
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1770883332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENTALLY ILL KIDS IN DISTRESS

Provider Business Mailing Address
First Line	:	7816 N 19TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-7036
Country	:	US
Telephone Number	:	480-414-4879
Fax Number	:	602-253-1250

Provider Business Practice Location Address
First Line	:	810 GEMSTONE AVE STE 1&2&3
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-6476
Country	:	US
Telephone Number	:	928-733-0093
Fax Number	:	928-636-9904

Authorized Official
Title or Position	:	CEO
Name	:	MATT AUNA
Credential	:	BHT
Telephone Number	:	480-414-4879

Provider Enumeration Date	:	10/29/2010
Last Update Date	:	12/05/2025

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