Healthcare Provider Details

I. General information

NPI: 1740487222
Provider Name (Legal Business Name): FAMILY SERVICE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 S GILBERT RD SUITE 104
MESA AZ
85204-5232
US

IV. Provider business mailing address

PO BOX 86537
TUCSON AZ
85754-6537
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-9891
  • Fax: 602-234-2639
Mailing address:
  • Phone: 520-721-1887
  • Fax: 520-721-0069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberBH-1277
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberOTC8084
License Number StateAZ

VIII. Authorized Official

Name: ROSE M LOPEZ
Title or Position: PRESIDENT AND CEO
Credential: MBA
Phone: 520-721-1887