Healthcare Provider Details

I. General information

NPI: 1124407390
Provider Name (Legal Business Name): SEQUELCARE OF ARIZONA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8603 E EASTRIDGE RD
PRESCOTT VALLEY AZ
86314-8562
US

IV. Provider business mailing address

3656 PACKSADDLE RD
KINGMAN AZ
86401-6524
US

V. Phone/Fax

Practice location:
  • Phone: 928-777-3280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number467011
License Number StateAZ

VIII. Authorized Official

Name: TRACIE HIRZ
Title or Position: HCTC PROVIDER
Credential:
Phone: 928-777-3280