1336190115 NPI number — SOUTHWEST CENTER FOR COMMUNICATION DISORDERS

Table of content: (NPI 1336190115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336190115 NPI number — SOUTHWEST CENTER FOR COMMUNICATION DISORDERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST CENTER FOR COMMUNICATION DISORDERS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336190115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
802 AINSWORTH DR
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86301-1630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-777-0172
Provider Business Mailing Address Fax Number:
928-777-0174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 AINSWORTH DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86301-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-777-0172
Provider Business Practice Location Address Fax Number:
928-777-0174
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRUJIDO
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ADMINISTRATOR
Authorized Official Telephone Number:
928-777-0172

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW-3469 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 235Z00000X , with the licence number: 0732 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036593 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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