Basic Information
| Provider Information | |||||||||
| NPI: | 1912164039 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 N CENTRAL AVE | ||||||||
| Address2: | SUITE 1050 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022668402 | ||||||||
| FaxNumber: | 6022640887 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 N 95TH AVE STE 132 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850374445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239326950 | ||||||||
| FaxNumber: | 6239327995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HENNING | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6022854340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | OTC6612 | AZ | N | Agencies | Case Management | 251S00000X | OTC6612 | AZ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | Z127516 | 01 | AZ | MEDICARE PTAN | OTHER | 361554 | 05 | AZ | MEDICAID |