Healthcare Provider Details

I. General information

NPI: 1285968024
Provider Name (Legal Business Name): ABC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 HIWAY 95 STE N-104
BULLHEAD CITY AZ
86442-7860
US

IV. Provider business mailing address

3003 HIWAY 95 STE N-104
BULLHEAD CITY AZ
86442-7860
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-0250
  • Fax: 928-763-0271
Mailing address:
  • Phone: 928-763-0250
  • Fax: 928-763-0271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number1697
License Number StateAZ

VIII. Authorized Official

Name: MRS. LAREE A JONES
Title or Position: BUSINESS OFFICE ADMINISTRATOR
Credential: B.S.
Phone: 928-763-4796