Basic Information
| Provider Information | |||||||||
| NPI: | 1265791586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARIZONA THERAPEUTIC LEARNING CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6022305105 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6022305105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2012 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAYLESS | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6022307373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.