MEDICARE: PARADISE VALLEY BEHAVIORAL HEALTH

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	BH5158	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BH5158	OTHER	AZ	DEPARTMENT OF BEHAVIORAL HEALTH

General Provider Information

NPI Number	:	1417468398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARADISE VALLEY BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	3015 E GELDING DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-5032
Country	:	US
Telephone Number	:	602-400-2288
Fax Number	:

Provider Business Practice Location Address
First Line	:	13401 N 30TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-6028
Country	:	US
Telephone Number	:	602-400-2288
Fax Number	:	602-996-1577

Authorized Official
Title or Position	:	PROGRAM DIRECTOR / OWNER
Name	:	DAVID CARDOSO
Credential	:
Telephone Number	:	602-400-2288

Provider Enumeration Date	:	10/18/2017
Last Update Date	:	10/18/2017

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