Healthcare Provider Details

I. General information

NPI: 1487984720
Provider Name (Legal Business Name): DESERT MILAGROS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2010
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3438 N. COUNTRY CLUB ROAD
TUCSON AZ
85716-1257
US

IV. Provider business mailing address

3438 N. COUNTRY CLUB ROAD
TUCSON AZ
85716-1257
US

V. Phone/Fax

Practice location:
  • Phone: 520-531-1040
  • Fax: 520-325-1040
Mailing address:
  • Phone: 520-531-1040
  • Fax: 520-325-1040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberOTC6580
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberBH3142
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberBH3142
License Number StateAZ

VIII. Authorized Official

Name: FAITH VALENTINA SUASO
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 520-531-1040