Basic Information
Provider Information | |||||||||
NPI: | 1457746497 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PASADERA BEHAVIORAL HEALTH NETWORK, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DODGE DETOXIFICATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2700 S 8TH AVE | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857134730 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206283400 | ||||||||
FaxNumber: | 5206283401 | ||||||||
Practice Location | |||||||||
Address1: | 2502 N DODGE BLVD | ||||||||
Address2: | SUITE 190 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857162671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206188600 | ||||||||
FaxNumber: | 5206171608 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2015 | ||||||||
LastUpdateDate: | 08/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OLIVER | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF QUALITY MANAGEMENT OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5206283400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PASADERA BEHAVIORAL HEALTH NETWORK, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC, RMM, ICD10CT-CM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | IFBH7082 | AZ | Y |   | Hospital Units | Rehabilitation, Substance Use Disorder Unit |   |
ID Information
ID | Type | State | Issuer | Description | 019108 | 05 | AZ |   | MEDICAID | IFBH7082 | 01 | AZ | STATE LICENSE | OTHER |