Healthcare Provider Details

I. General information

NPI: 1134292485
Provider Name (Legal Business Name): LITTLE COLORADO BEHAVIORAL HEALTH CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 W CLEVELAND ST
SAINT JOHNS AZ
85936-4501
US

IV. Provider business mailing address

PO BOX 579
SAINT JOHNS AZ
85936-0579
US

V. Phone/Fax

Practice location:
  • Phone: 928-337-4301
  • Fax: 928-337-2269
Mailing address:
  • Phone: 928-337-4301
  • Fax: 928-337-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN HOGEBOOM
Title or Position: CEO
Credential:
Phone: 480-831-7566