Basic Information
| Provider Information | |||||||||
| NPI: | 1316284714 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARIZONA THERAPEUTIC LEARNING CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRILLIUM INTEGRATED HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 E CAMELBACK RD | ||||||||
| Address2: | #155 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6026827455 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6022305102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2013 | ||||||||
| LastUpdateDate: | 04/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | KUHN | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6022307373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | BH-4082 | AZ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 709972 | 05 | AZ | MEDICAID |