Basic Information
| Provider Information | |||||||||
| NPI: | 1558609222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANYONLANDS COMMUNITY HEALTHCARE - BH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1625 | ||||||||
| Address2: | |||||||||
| City: | PAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286459675 | ||||||||
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| Practice Location | |||||||||
| Address1: | 467 VISTA AVENUE | ||||||||
| Address2: | |||||||||
| City: | PAGE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286459675 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2013 | ||||||||
| LastUpdateDate: | 01/30/2013 | ||||||||
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| AuthorizedOfficialLastName: | LATHAM | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9286459675 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CANYONLANDS COMMUNITY HEALTHCARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | BH-4088 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TP0016X | BH-4088 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) | 103TP2701X | BH-4088 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TC0700X | BH-4088 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 432857 | 05 | AZ | MEDICAID |