Healthcare Provider Details

I. General information

NPI: 1750335311
Provider Name (Legal Business Name): WEST YAVAPAI GUIDANCE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 DAMERON DR
PRESCOTT AZ
86301-2411
US

IV. Provider business mailing address

3343 N. WINDSONG DR.
PRESCOTT VALLEY AZ
86314-2283
US

V. Phone/Fax

Practice location:
  • Phone: 928-445-5211
  • Fax: 928-776-8484
Mailing address:
  • Phone: 928-445-5211
  • Fax: 928-776-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberBH309
License Number StateAZ

VIII. Authorized Official

Name: KARA LANGLEY
Title or Position: CAO
Credential:
Phone: 928-445-5211