Basic Information
| Provider Information | |||||||||
| NPI: | 1437307774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RECOVERY EMPOWERMENT NETWORK, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 E. OSBORN RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022480368 | ||||||||
| FaxNumber: | 6022792806 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 E. OSBORN RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022480368 | ||||||||
| FaxNumber: | 6022792806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2008 | ||||||||
| LastUpdateDate: | 01/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | ANTTILAINEN | ||||||||
| AuthorizedOfficialFirstName: | KIRSTEN | ||||||||
| AuthorizedOfficialMiddleName: | ELISA | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE & CREDENTIALING COOR | ||||||||
| AuthorizedOfficialTelephone: | 6022480368 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CSA08ADHS0187 | AZ | N | Agencies | Community/Behavioral Health | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 073523 | 05 | AZ | MEDICAID |