Healthcare Provider Details

I. General information

NPI: 1811109762
Provider Name (Legal Business Name): KAYENTA OUTPATIENT TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 394.3 US-160
KAYENTA AZ
86033-0487
US

IV. Provider business mailing address

PO BOX 487
KAYENTA AZ
86033-0487
US

V. Phone/Fax

Practice location:
  • Phone: 928-697-5570
  • Fax: 928-697-5574
Mailing address:
  • Phone: 928-697-5570
  • Fax: 928-697-5574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MIRANDA BLATCHFORD
Title or Position: BEHAVIORAL HEALTH DIRECTOR
Credential: LCSW
Phone: 928-697-5570