Basic Information
| Provider Information | |||||||||
| NPI: | 1679756621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAVEN SENDERO DE SONORA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6050 N CORONA RD BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857041097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204698700 | ||||||||
| FaxNumber: | 5208782320 | ||||||||
| Practice Location | |||||||||
| Address1: | 2502 N DODGE BLVD STE 160 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857162674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206188901 | ||||||||
| FaxNumber: | 5206188902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2007 | ||||||||
| LastUpdateDate: | 12/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5204698700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 102L00000X | BH2869 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychoanalyst |
ID Information
| ID | Type | State | Issuer | Description | 156993 | 01 | AZ | AHCCCS | OTHER | 1184814550 | 01 | AZ | NPI | OTHER |