Provider Demographics
NPI:1033163514
Name:WEST YAVAPAI GUIDANCE CLINIC, INC.
Entity Type:Organization
Organization Name:WEST YAVAPAI GUIDANCE CLINIC, INC.
Other - Org Name:HADDON HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PLAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-445-5211
Mailing Address - Street 1:642 DAMERON DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-2411
Mailing Address - Country:US
Mailing Address - Phone:928-445-5211
Mailing Address - Fax:928-717-1204
Practice Address - Street 1:711 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-445-5211
Practice Address - Fax:928-717-1204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST YAVAPAI GUIDANCE CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH1394320600000X
AZBH-1394320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ692229Medicaid
AZ692229Medicaid
AZZWCHHDMedicare UPIN