Healthcare Provider Details

I. General information

NPI: 1780788240
Provider Name (Legal Business Name): PASADERA BEHAVIORAL HEALTH NETWORK DBA LEVEL II DETOXIFICATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 N. DODGE BLVD.
TUCSON AZ
85716-2012
US

IV. Provider business mailing address

2502 N. DODGE BLVD. SUITE 190
TUCSON AZ
85716-2675
US

V. Phone/Fax

Practice location:
  • Phone: 520-628-3155
  • Fax: 520-628-3158
Mailing address:
  • Phone: 520-618-8622
  • Fax: 520-617-1608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberBH/H-3958
License Number StateAZ

VIII. Authorized Official

Name: GROVER GLENN
Title or Position: DIRECTOR OF QM
Credential: MA, LPC, LISAC, CPHQ
Phone: 520-618-8622