Healthcare Provider Details

I. General information

NPI: 1760906440
Provider Name (Legal Business Name): EASTER SEALS BLAKE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S MEYER AVE
TUCSON AZ
85701-2207
US

IV. Provider business mailing address

7750 E BROADWAY BLVD STE A200
TUCSON AZ
85710-3901
US

V. Phone/Fax

Practice location:
  • Phone: 520-622-3933
  • Fax: 520-670-9221
Mailing address:
  • Phone: 520-327-1529
  • Fax: 520-327-1836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCSL8349
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MARISSA S ARENDT
Title or Position: CFO
Credential:
Phone: 520-327-1529