Healthcare Provider Details

I. General information

NPI: 1144332107
Provider Name (Legal Business Name): HIGH COUNTRY EARLY INTERVENTION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 CLEARWATER DR SUITE B
PRESCOTT AZ
86305-7166
US

IV. Provider business mailing address

3160 STILLWATER DR STE B
PRESCOTT AZ
86305-7151
US

V. Phone/Fax

Practice location:
  • Phone: 928-776-9285
  • Fax: 928-776-7753
Mailing address:
  • Phone: 928-776-4349
  • Fax: 928-776-1369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number4192
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number3724
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number4192
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number3724
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number4192
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5331
License Number StateAZ
# 10
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MISS ANNA M MANCHA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 928-776-9285