Basic Information
| Provider Information | |||||||||
| NPI: | 1336632496 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHWAYS OF ARIZONA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1161 N EL DORADO PL | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857154607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207487108 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2830 W GLENDALE AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024554626 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | POE | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACTS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5205701460 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PATHWAYS HEALTH AND COMMUNITY SUPPORT,LLC | ||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 000285 | 05 | AZ | MEDICAID |