Provider Demographics
NPI:1043615412
Name:TELECARE MENTAL HEALTH SERVICES OF ARIZONA INC
Entity Type:Organization
Organization Name:TELECARE MENTAL HEALTH SERVICES OF ARIZONA INC
Other - Org Name:TELECARE YUMA ACT
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER RELATIONS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-337-7950
Mailing Address - Street 1:1080 MARINA VILLAGE PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1087
Mailing Address - Country:US
Mailing Address - Phone:510-337-7950
Mailing Address - Fax:510-337-7969
Practice Address - Street 1:1595 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4706
Practice Address - Country:US
Practice Address - Phone:928-329-5855
Practice Address - Fax:928-329-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC6996261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ986992Medicaid