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General NPI Number Information
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NPI Number | 1144382524
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Entity Type | Organization
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Legal Business Name | COMMUNITY INTERVENTION ASSOCIAGTES
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Dates
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Enumeration Date | 12/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3802 W 16TH ST
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City | YUMA
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State | AZ
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Zip | 85364-4107
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Country | US
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Telephone | 928-376-0026
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Fax | 928-782-2298
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Provider Business Mailing Address
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Address Line | 3802 W 16TH ST
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City | YUMA
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State | AZ
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Zip | 85364-4107
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Country | US
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Telephone | 928-376-0026
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Fax | 928-782-2298
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Authorized Official
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Title or Position | CLINICAL LIAISON
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Name | GUSTAVO ALBERT RODRIGUEZ
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Credential | LISAC
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Telephone | 928-376-0026
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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 | LISAC-1257
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License Number State | AZ
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