MEDICARE: LITTLE COLORADO BEHAVIORAL HEALTH CENTER INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134292485
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE COLORADO BEHAVIORAL HEALTH CENTER INC.

Provider Business Mailing Address
First Line	:	PO BOX 579
Second Line	:
City	:	SAINT JOHNS
State	:	AZ
Zip	:	85936-0579
Country	:	US
Telephone Number	:	928-337-4301
Fax Number	:	928-337-2269

Provider Business Practice Location Address
First Line	:	470 W CLEVELAND ST
Second Line	:
City	:	SAINT JOHNS
State	:	AZ
Zip	:	85936-4501
Country	:	US
Telephone Number	:	928-337-4301
Fax Number	:	928-337-2269

Authorized Official
Title or Position	:	CEO
Name	:	MR. JOHN HOGEBOOM
Credential	:
Telephone Number	:	480-831-7566

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	09/18/2024

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