Healthcare Provider Details

I. General information

NPI: 1124016019
Provider Name (Legal Business Name): SOUTHEASTERN ARIZONA BEHAVIORAL HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N DOUGLAS AVE
DOUGLAS AZ
85607-1019
US

IV. Provider business mailing address

P.O. BOX 2161 611 W. UNION STREET
BENSON AZ
85602
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-1286
  • Fax: 520-805-1221
Mailing address:
  • Phone: 520-586-0800
  • Fax: 520-586-0116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberBH-1896
License Number StateAZ

VIII. Authorized Official

Name: ESTELLA HERNANDEZ
Title or Position: CONTRACTS & CREDENTIALING ADMIN
Credential: MBA
Phone: 520-838-5513