Healthcare Provider Details

I. General information

NPI: 1013524230
Provider Name (Legal Business Name): CIVARA BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W CACTUS RD
PHOENIX AZ
85029-2905
US

IV. Provider business mailing address

7020 E MORELAND ST
SCOTTSDALE AZ
85257-3318
US

V. Phone/Fax

Practice location:
  • Phone: 480-329-9585
  • Fax: 602-237-5211
Mailing address:
  • Phone: 480-329-9585
  • Fax: 602-237-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: VITTELIAN FORBES
Title or Position: OWNER
Credential: PHARMD
Phone: 480-329-9585