Provider Demographics
NPI:1043028673
Name:WESTSIDE BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:WESTSIDE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TII
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMBILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-279-2661
Mailing Address - Street 1:853 PALA MESA DR
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3923
Mailing Address - Country:US
Mailing Address - Phone:928-279-2661
Mailing Address - Fax:
Practice Address - Street 1:853 PALA MESA DR
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3923
Practice Address - Country:US
Practice Address - Phone:928-279-2661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities