Basic Information
| Provider Information | |||||||||
| NPI: | 1295157972 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PASADERA BEHAVIORAL HEALTH NETWORK, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PASADERA GREEN VALLEY SITE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 S 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857134730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206188622 | ||||||||
| FaxNumber: | 5206283401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 S. CAMPBELL RD. | ||||||||
| Address2: | BUILDING 2 | ||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856140503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204075400 | ||||||||
| FaxNumber: | 5204075990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2014 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLIVER | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF QUALITY MANAGEMENT OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5206283400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PASADERA BEHAVIORAL HEALTH NETWORK, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC, RMM, ICD10CT-CM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | OTC6176 | AZ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | OTC6176 | 01 | AZ | STATE LICENSE | OTHER | 882111 | 05 | AZ | MEDICAID |