Basic Information
| Provider Information | |||||||||
| NPI: | 1790861243 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOHAVE MENTAL HEALTH CLINIC INC | ||||||||
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| 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: | 1145 MARINA BLVD | ||||||||
| Address2: | |||||||||
| City: | BULLHEAD CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287585905 | ||||||||
| FaxNumber: | 9287588790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | ABBOTT | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9287578111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA, LPC | ||||||||
| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | BH1474 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | 261Q00000X | OTC6117 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.