MEDICARE: SPRINGBROOK HABILITATION SERVICES, LLC

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	320800000X	Mental Illness Community Based Residential Treatment Facility	BH-2586	AZ

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	:	1336310275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRINGBROOK HABILITATION SERVICES, LLC

Provider Business Mailing Address
First Line	:	4835 E CACTUS RD
Second Line	:	SUITE # 460
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85254-4191
Country	:	US
Telephone Number	:	602-424-1838
Fax Number	:	602-424-7879

Provider Business Practice Location Address
First Line	:	3843 E LARKSPUR DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-7345
Country	:	US
Telephone Number	:	602-595-3025
Fax Number	:	602-595-6029

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MR. GEORGE W GREEN JR.
Credential	:	M.ED.
Telephone Number	:	602-424-1838

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	12/28/2009

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