Organization
OLIVE BRANCH BEHAVIORAL RESIDENCIAL NETWORK, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. TRACY BARSHELL KETCHUM (CAO,ADMINISTRATOR)
(708) 277-8673
Entity
Organization
Contact information
Practice address
2421 E ROBERT E LEE ST, PHOENIX, AZ 85032-1082
(602) 569-0806
(602) 569-0537
Mailing address
15712 W EUCALYPTUS CT, SURPRISE, AZ 85374-3308
(708) 277-8673
Taxonomy
Speciality
Code
Description
License number
State
2084B0040X
Behavioral Neurology & Neuropsychiatry Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1028196670
BEHAVIORAL HEALTH
AZ
Enumeration date
12/05/2019
Last updated
12/05/2019
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