Healthcare Provider Details

I. General information

NPI: 1538497912
Provider Name (Legal Business Name): SOUTHWEST NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 N MESA DR SUITE 201
MESA AZ
85201-5973
US

IV. Provider business mailing address

2700 N CENTRAL AVE SUITE 1050
PHOENIX AZ
85004-1133
US

V. Phone/Fax

Practice location:
  • Phone: 480-838-5550
  • Fax: 480-756-8201
Mailing address:
  • Phone: 602-266-8402
  • Fax: 602-264-0887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberOTC6259
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberOTC6259
License Number StateAZ

VIII. Authorized Official

Name: MS. AMY B. HENNING
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 602-285-4340