MEDICARE: PANTANO BEHAVIORAL HEALTH SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center	BH-2183	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	772576	OTHER	AZ	AHCCCS ID

General Provider Information

NPI Number	:	1205842705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANTANO BEHAVIORAL HEALTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	5055 E BROADWAY BLVD STE C104
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3641
Country	:	US
Telephone Number	:	520-623-9833
Fax Number	:	520-623-9083

Provider Business Practice Location Address
First Line	:	5055 E BROADWAY BLVD STE C104
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3641
Country	:	US
Telephone Number	:	520-623-9833
Fax Number	:	520-623-9083

Authorized Official
Title or Position	:	DIRECTOR OF FINANCE
Name	:	MARISSA S ARENDT
Credential	:	CFE
Telephone Number	:	520-623-9833

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	11/14/2012

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