=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871764746
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGELLAN HEALTH SERVICES - TEMPE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2008
-----------------------------------------------------
Last Update Date | 03/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1225 E BROADWAY RD
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-929-5100
-----------------------------------------------------
Fax | 480-731-1066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1225 E BROADWAY RD
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-1525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-929-5100
-----------------------------------------------------
Fax | 480-731-1066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED NUSE - CLINIC
-----------------------------------------------------
Name | MRS. MARY M. DEFFENBAUGH
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 480-929-5100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------