Basic Information
| Provider Information | |||||||||
| NPI: | 1609079235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARAKA HOUSE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BARAKA HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10000 N 31ST AVE STE A107 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850519582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024412388 | ||||||||
| FaxNumber: | 8005240824 | ||||||||
| Practice Location | |||||||||
| Address1: | 3740 W CARON ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850513340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022498900 | ||||||||
| FaxNumber: | 6022498900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2007 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OKORIE | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6025240824 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.A., PH.D., LPC | ||||||||
| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3104A0625X | BH2753 | AZ | Y | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | BH2753 | 01 | AZ | BEHAVIORAL HEALTH LICENSE | OTHER | 114301 | 05 | AZ | MEDICAID |