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General NPI Number Information
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NPI Number | 1194027847
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Entity Type | Organization
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Legal Business Name | SAN TAN BEHAVIORAL HEALTH SERVICES
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Dates
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Enumeration Date | 12/01/2010
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Last Update Date | 12/01/2010
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Provider Practice Location Address
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Address Line | 655 SOUTHLAKE RD
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City | LAKESIDE
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State | AZ
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Zip | 85929-6768
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Country | US
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Telephone | 928-358-1087
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Fax | 480-632-0026
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Provider Business Mailing Address
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Address Line | 2451 E BASELINE RD
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City | GILBERT
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State | AZ
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Zip | 85234-2471
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Country | US
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Telephone | 480-507-3644
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Fax | 480-632-0026
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Authorized Official
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Title or Position | CHIEF CLINICAL OFFICER
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Name | MELISSA DAWN NELSON
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Credential | M.A., L.P.C.
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Telephone | 480-507-3644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number | BH3755
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 385HR2055X
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Taxonomy Name | Child Mental Illness Respite Care
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License Number | BH3755
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License Number State | AZ
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