Healthcare Provider Details

I. General information

NPI: 1649676040
Provider Name (Legal Business Name): DESERT PATH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12170 E CORNVILLE RD
CORNVILLE AZ
86325-5260
US

IV. Provider business mailing address

12170 E CORNVILLE RD
CORNVILLE AZ
86325-5260
US

V. Phone/Fax

Practice location:
  • Phone: 928-301-4596
  • Fax: 928-708-9620
Mailing address:
  • Phone: 928-301-4596
  • Fax: 928-708-9620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: LINDA CATHCART
Title or Position: CEO
Credential:
Phone: 928-301-4596