Basic Information
| Provider Information | |||||||||
| NPI: | 1811382021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CIRCLE THE CITY BEHAVIORAL HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 W INDIAN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027769000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 W INDIAN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027769000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2015 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 6027769000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CIRCLE THE CITY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | UNC5520 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 012453 | 05 | AZ | MEDICAID |