Healthcare Provider Details

I. General information

NPI: 1144382524
Provider Name (Legal Business Name): COMMUNITY INTERVENTION ASSOCIAGTES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 W 16TH ST
YUMA AZ
85364-4107
US

IV. Provider business mailing address

3802 W 16TH ST
YUMA AZ
85364-4107
US

V. Phone/Fax

Practice location:
  • Phone: 928-376-0026
  • Fax: 928-782-2298
Mailing address:
  • Phone: 928-376-0026
  • Fax: 928-782-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-1257
License Number StateAZ

VIII. Authorized Official

Name: GUSTAVO ALBERT RODRIGUEZ
Title or Position: CLINICAL LIAISON
Credential: LISAC
Phone: 928-376-0026