1588061634 NPI number — NORTHERN ARIZONA MED-PSYCH CLINIC, PLLC

Table of content: (NPI 1588061634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588061634 NPI number — NORTHERN ARIZONA MED-PSYCH CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN ARIZONA MED-PSYCH CLINIC, PLLC
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:
6
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:
1588061634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
989 S MAIN ST
Provider Second Line Business Mailing Address:
BOX 447
Provider Business Mailing Address City Name:
COTTONWOOD
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86326-4601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-821-3403
Provider Business Mailing Address Fax Number:
928-282-1852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2155 W SR 89A
Provider Second Line Business Practice Location Address:
ST 105
Provider Business Practice Location Address City Name:
SEDONA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86336-5468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-821-3403
Provider Business Practice Location Address Fax Number:
928-282-1852
Provider Enumeration Date:
12/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TOLLESON
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
COLLEEN
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
928-821-5173

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  36928 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 36928 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 231772 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000092216 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 000085117 . This is a "MEDICARE ID" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 36928 . This is a "ARIZONA MEDICAL BOARD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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