MEDICARE: MRS. CRISANTA T HANNAH NONE

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	320800000X	Mental Illness Community Based Residential Treatment Facility	2721	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	921503	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1255478889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRISANTA T HANNAH NONE

Provider Business Mailing Address
First Line	:	7151 W VALLEY STREAM DRIVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757-1422
Country	:	US
Telephone Number	:	520-888-0810
Fax Number	:	520-319-5491

Provider Business Practice Location Address
First Line	:	7151 W VALLEY STREAM DRIVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757-1422
Country	:	US
Telephone Number	:	520-888-0810
Fax Number	:	520-319-5491

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	01/18/2008

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