=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003059585
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY ALLIANCE FOR YOUTH AND FAMILLY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2009
-----------------------------------------------------
Last Update Date | 04/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23568 N OASIS BLVD
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85232-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-723-1337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23568 N OASIS BLVD
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85232-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-723-1337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. SHERMAINE NOEL FORT
-----------------------------------------------------
Credential | B.S.
-----------------------------------------------------
Telephone | 480-703-4143
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 3179
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------