Organization
OLIVE BRANCH BEHAVIORAL RESIDENCIAL NETWORK, LLC
Active
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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