Organization
DIRECTLY AFFECTED
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DOMINIQUE MYRICK (PRESIDENT)
(614) 980-2116
Entity
Organization
Contact information
Practice address
2522 S TERRIPIN, MESA, AZ 85209-4959
(614) 980-2116
Mailing address
2522 S TERRIPIN, MESA, AZ 85209-4959
(614) 980-2116
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
251B00000X
Case Management Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
253J00000X
Foster Care Agency
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
—
—
Other
Enumeration date
03/10/2021
Last updated
03/10/2021
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