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General NPI Number Information
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NPI Number | 1083835458
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Entity Type | Organization
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Legal Business Name | KAIBETO OUTPATIENT TREATMENT CENTER
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 03/10/2022
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Provider Practice Location Address
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Address Line | 0.5 MILE SOUTH OF KAIBETO MARKET
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City | KAIBETO
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State | AZ
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Zip | 86053-2147
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Country | US
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Telephone | 928-673-3267
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Fax | 928-673-3269
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Provider Business Mailing Address
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Address Line | PO BOX 2147
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City | KAIBETO
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State | AZ
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Zip | 86053-2147
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Country | US
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Telephone | 928-673-3267
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Fax | 928-673-3269
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Authorized Official
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Title or Position | BEHAVIORAL HEALTH DIRECTOR
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Name | JANELL DICKSON
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Credential | M.A., M.ED., LPC
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Telephone | 928-673-3267
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 822909
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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