Provider Demographics
NPI:1033895263
Name:DESERT VILLAGE THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:DESERT VILLAGE THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GOLLENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:520-222-6693
Mailing Address - Street 1:2450 E SPEEDWAY BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-4748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 E SPEEDWAY BLVD STE 3
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-4748
Practice Address - Country:US
Practice Address - Phone:520-222-6693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty