Basic Information
| Provider Information | |||||||||
| NPI: | 1629499165 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EBH SOUTHWEST SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PROMISES SCOTTSDALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670595 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752679585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155677256 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12816 E TURQUOISE AVE | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852595300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808402588 | ||||||||
| FaxNumber: | 4807737340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2013 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAPLESDEN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6155103708 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELEMENTS BEHAVORIAL HEALTH, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC, CHC, CHPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | BH4435 | AZ | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.