Basic Information
| Provider Information | |||||||||
| NPI: | 1427554708 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS BLAKE FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7750 E. BROADWAY BLVD | ||||||||
| Address2: | SUITE A-200 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203271529 | ||||||||
| FaxNumber: | 5202697080 | ||||||||
| Practice Location | |||||||||
| Address1: | 3860 WEST 24TH STREET | ||||||||
| Address2: | SUITES 201-208 | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282769225 | ||||||||
| FaxNumber: | 9282764313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2018 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | ARENDT | ||||||||
| AuthorizedOfficialFirstName: | MARISSA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5203271529 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251S00000X | OTC8701 | AZ | Y | Agencies | Community/Behavioral Health |
No ID Information.