Healthcare Provider Details

I. General information

NPI: 1275978900
Provider Name (Legal Business Name): COPPER CANYON ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 CORONADO TRAIL
LAKE MONTEZUMA AZ
86335
US

IV. Provider business mailing address

PO BOX 230
RIMROCK AZ
86335-0230
US

V. Phone/Fax

Practice location:
  • Phone: 928-567-1322
  • Fax:
Mailing address:
  • Phone: 928-567-1322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ARIELLA ALLAMAN
Title or Position: THERAPIST
Credential: MA, LAC
Phone: 928-567-1322