Basic Information
| Provider Information | |||||||||
| NPI: | 1518014927 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMANCE ENHANCEMENT AND REHABILITATION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3295 W INA RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857412192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205472062 | ||||||||
| FaxNumber: | 5205472065 | ||||||||
| Practice Location | |||||||||
| Address1: | 3295 W INA RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857412192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205472062 | ||||||||
| FaxNumber: | 5205472065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | HEUVELMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 5207429166 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 1298I | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1298I | 01 | AZ | LICENSE | OTHER |