Basic Information
| Provider Information | |||||||||
| NPI: | 1487767760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RECOVERY EMPOWERMENT NETWORK OF MARICOPA COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7732 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850117732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022480368 | ||||||||
| FaxNumber: | 6022661958 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 W INDIAN SCHOOL ROAD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022480368 | ||||||||
| FaxNumber: | 6022661958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RIDER | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6022480368 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MSW CPRP | ||||||||
| NPICertificationDate: | |||||||||
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 | CSA06ADHS0187 | 01 | AZ | DBHS | OTHER |