MEDICARE: FORT DEFIANCE OUTPATIENT TREATMENT CENTER

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
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	:	1740400365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT DEFIANCE OUTPATIENT TREATMENT CENTER

Provider Business Mailing Address
First Line	:	PO BOX 1490
Second Line	:
City	:	FORT DEFIANCE
State	:	AZ
Zip	:	86504-1490
Country	:	US
Telephone Number	:	928-729-4012
Fax Number	:	928-729-4200

Provider Business Practice Location Address
First Line	:	.5 MILES SW OF THE FD FIELD HOUSE BLDG #6905
Second Line	:
City	:	FORT DEFIANCE
State	:	AZ
Zip	:	86504-1490
Country	:	US
Telephone Number	:	928-729-4012
Fax Number	:	928-729-4200

Authorized Official
Title or Position	:	BEHAVIORAL HEALTH DIRECTOR
Name	:	MIRANDA BLATCHFORD
Credential	:	LCSW
Telephone Number	:	928-729-4012

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	03/10/2022

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Directions to “FORT DEFIANCE OUTPATIENT TREATMENT CENTER ” Practice Location

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