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General NPI Number Information
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NPI Number | 1841636776
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Entity Type | Organization
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Legal Business Name | SAN PEDRO HEALTH
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Dates
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Enumeration Date | 05/19/2013
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Last Update Date | 05/19/2013
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Provider Practice Location Address
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Address Line | 4151 LA LINDA WAY STE 102
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-4600
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Country | US
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Telephone | 520-515-9610
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Fax |
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Provider Business Mailing Address
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Address Line | 4151 LA LINDA WAY STE 102
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-4600
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Country | US
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Telephone | 520-515-9610
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | BROOKE MANSOUR
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Credential |
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Telephone | 520-515-9610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LAMFT-10301
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License Number State | AZ
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