Basic Information
| Provider Information | |||||||||
| NPI: | 1639367105 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST YAVAPAI GUIDANCE CLINIC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WINDHAVEN PSYCHIATRIC HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3343 N WINDSONG DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863141213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Practice Location | |||||||||
| Address1: | 3343 N WINDSONG DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863141213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/08/2018 | ||||||||
| NPIReactivationDate: | 09/21/2018 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANGLEY | ||||||||
| AuthorizedOfficialFirstName: | KARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER/CAO | ||||||||
| AuthorizedOfficialTelephone: | 9284455211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST YAVAPAI GUIDANCE CLINIC, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | BH 309 | AZ | N | Hospitals | Psychiatric Hospital | 324500000X | BH 309 | AZ | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.