Healthcare Provider Details

I. General information

NPI: 1033163514
Provider Name (Legal Business Name): WEST YAVAPAI GUIDANCE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 HILLSIDE AVE
PRESCOTT AZ
86301
US

IV. Provider business mailing address

642 DAMERON DR STE B
PRESCOTT AZ
86301-2411
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-5211
  • Fax: 928-717-1204
Mailing address:
  • Phone: 928-445-5211
  • Fax: 928-717-1204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberBH1394
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH-1394
License Number StateAZ

VIII. Authorized Official

Name: MRS. TAMARA PLAYER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 928-445-5211