Provider Demographics
NPI:1366101479
Name:SHALOM BEHAVIORAL HOUSE, LLC
Entity type:Organization
Organization Name:SHALOM BEHAVIORAL HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AIME
Authorized Official - Middle Name:MUKURA LINDA
Authorized Official - Last Name:MINEGA SHABANI
Authorized Official - Suffix:
Authorized Official - Credentials:CNA/BHT
Authorized Official - Phone:855-895-0261
Mailing Address - Street 1:8050 N 19TH AVE UNIT 151
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5160
Mailing Address - Country:US
Mailing Address - Phone:855-895-0261
Mailing Address - Fax:855-755-9202
Practice Address - Street 1:11063 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5889
Practice Address - Country:US
Practice Address - Phone:855-895-0261
Practice Address - Fax:855-755-9202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health