Basic Information
Provider Information | |||||||||
NPI: | 1356831911 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COZZA WITHDRAWAL MANAGEMENT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 141106 | ||||||||
Address2: |   | ||||||||
City: | SPOKANE VALLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 992141106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 44 E COZZA DR STE B | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992086514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5092325766 | ||||||||
FaxNumber: | 5093215472 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2018 | ||||||||
LastUpdateDate: | 05/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STRETCH | ||||||||
AuthorizedOfficialFirstName: | TIFFANY | ||||||||
AuthorizedOfficialMiddleName: | DAWN | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5092325766 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   |   | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
No ID Information.