MEDICARE: SOUTHEASTERN ARIZONA BEHAVIORAL HEALTH SERVICE, 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	251K00000X	Public Health or Welfare Agency	BH-2672	AZ
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
2	OTC-6143	OTHER	AZ	ADHS LICENSING

General Provider Information

NPI Number	:	1790773620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN ARIZONA BEHAVIORAL HEALTH SERVICE, INC.

Provider Business Mailing Address
First Line	:	611 W UNION ST
Second Line	:
City	:	BENSON
State	:	AZ
Zip	:	85602-6718
Country	:	US
Telephone Number	:	520-586-0800
Fax Number	:	520-586-0116

Provider Business Practice Location Address
First Line	:	404 W REX ALLEN DR
Second Line	:
City	:	WILLCOX
State	:	AZ
Zip	:	85643-1120
Country	:	US
Telephone Number	:	520-384-2521
Fax Number	:	520-384-0543

Authorized Official
Title or Position	:	EVP/COO
Name	:	KATHY GUZMAN WELLS
Credential	:
Telephone Number	:	520-838-5501

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	09/05/2025

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