Olive Branch Behavioral Residencial Network, LLC

Primary specialty

Behavioral Neurology & Neuropsychiatry PhysicianTaxonomy code 2084B0040X

Legal business name

OLIVE BRANCH BEHAVIORAL RESIDENCIAL NETWORK, LLC

Practice address

2421 E Robert E Lee St
Phoenix, AZ 85032-1082

Phone

(602) 569-0806

Fax

(602) 569-0537

NPI assigned

Dec 5, 2019

Last updated

Dec 5, 2019By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Tracy Barshell Ketchum

Title

Cao,Administrator

Phone

(708) 277-8673

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1575504000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1575504000000",
    "number": "1215574496",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15712 W EUCALYPTUS CT",
            "city": "SURPRISE",
            "state": "AZ",
            "postal_code": "853743308",
            "telephone_number": "708-277-8673"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2421 E ROBERT E LEE ST",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850321082",
            "telephone_number": "602-569-0806",
            "fax_number": "602-569-0537"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OLIVE BRANCH BEHAVIORAL RESIDENCIAL NETWORK, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-05",
        "last_updated": "2019-12-05",
        "status": "A",
        "authorized_official_last_name": "KETCHUM",
        "authorized_official_first_name": "TRACY",
        "authorized_official_middle_name": "BARSHELL",
        "authorized_official_title_or_position": "CAO,ADMINISTRATOR",
        "authorized_official_telephone_number": "708-277-8673",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "2084B0040X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Behavioral Neurology & Neuropsychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BEHAVIORAL HEALTH",
            "identifier": "1028196670",
            "state": "AZ"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "@OliveBranchBehavioral",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "2421 E Robert E Lee St",
            "city": "Phoenix",
            "state": "AZ",
            "country_code": "US",
            "postal_code": "850321082",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Amanda Olivas
• Kaitlyn Olivas
• Leslie O'Daniel Olivas, R.N.,B.S.N.
• Saira Maria Olivas, SLPA
• Olive Branch Behavioral Health
• Olive Grove Real Estate LLC
• Olive Tree Psychotherapy LLC
• Clay Oliver
• Coy E. Oliver, PNP
• Jessica Oliver, RBT

• Behavioral Neurology & Neuropsychiatry Physician in Phoenix, AZ
• Providers in Phoenix, AZ by specialty
• Behavioral Neurology & Neuropsychiatry Physician in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.