Basic Information
Provider Information | |||||||||
NPI: | 1689195901 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOHAVE MENTAL HEALTH CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3707 N STOCKTON HILL RD STE B | ||||||||
Address2: |   | ||||||||
City: | KINGMAN | ||||||||
State: | AZ | ||||||||
PostalCode: | 864090507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287578111 | ||||||||
FaxNumber: | 9287573256 | ||||||||
Practice Location | |||||||||
Address1: | 3745 N DIAMOND DR | ||||||||
Address2: |   | ||||||||
City: | KINGMAN | ||||||||
State: | AZ | ||||||||
PostalCode: | 864093328 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287578111 | ||||||||
FaxNumber: | 9287573256 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2017 | ||||||||
LastUpdateDate: | 06/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ABBOTT | ||||||||
AuthorizedOfficialFirstName: | DAWN | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9287578111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MA, LPC | ||||||||
NPICertificationDate: | 06/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | BH5202 | AZ | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
No ID Information.