Basic Information
Provider Information | |||||||||
NPI: | 1275845646 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PATHWAYS OF ARIZONA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1161 N EL DORADO PL | ||||||||
Address2: | SUITE 103 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857154607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207487108 | ||||||||
FaxNumber: | 5207450638 | ||||||||
Practice Location | |||||||||
Address1: | 1161 N EL DORADO PL | ||||||||
Address2: | SUITE 103 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207487108 | ||||||||
FaxNumber: | 5207450638 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2010 | ||||||||
LastUpdateDate: | 04/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POE | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTRACTS ADMINSITRATOR | ||||||||
AuthorizedOfficialTelephone: | 5205701460 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PATHWAYS HEALTH AND COMMUNITY SUPPRT LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | OTC6480 | AZ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 000284 | 05 | AZ |   | MEDICAID |