Basic Information
| Provider Information | |||||||||
| NPI: | 1831378793 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER PSYCHOLOGICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062837 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1920 N HIGLEY RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852341623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805432688 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | BH-3057 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 279741 | 05 | AZ | MEDICAID |