Basic Information
| Provider Information | |||||||||
| NPI: | 1548356207 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS BLAKE FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7750 E BROADWAY BLVD | ||||||||
| Address2: | SUITE A200 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203271529 | ||||||||
| FaxNumber: | 5203271836 | ||||||||
| Practice Location | |||||||||
| Address1: | 7750 E BROADWAY BLVD | ||||||||
| Address2: | SUITE A200 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203271529 | ||||||||
| FaxNumber: | 5203271836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| 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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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 385HR2065X | N | Respite Care Facility | Respite Care | Respite Care, Physical Disabilities, Child | 251B00000X | N | Agencies | Case Management | 320900000X | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 042622 | 05 | AZ | MEDICAID |