MEDICARE: COPPER CANYON ACADEMY

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LAC-13769	OTHER	AZ	AZ BOARD OF BEHAVIORAL HEALTH EXAMINERS

General Provider Information

NPI Number	:	1275978900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COPPER CANYON ACADEMY

Provider Business Mailing Address
First Line	:	PO BOX 230
Second Line	:
City	:	RIMROCK
State	:	AZ
Zip	:	86335-0230
Country	:	US
Telephone Number	:	928-567-1322
Fax Number	:

Provider Business Practice Location Address
First Line	:	3095 CORONADO TRAIL
Second Line	:
City	:	LAKE MONTEZUMA
State	:	AZ
Zip	:	86335
Country	:	US
Telephone Number	:	928-567-1322
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	ARIELLA ALLAMAN
Credential	:	MA, LAC
Telephone Number	:	928-567-1322

Provider Enumeration Date	:	05/08/2013
Last Update Date	:	05/16/2013

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Directions to “COPPER CANYON ACADEMY ” Practice Location

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