Provider Demographics
NPI:1043761182
Name:SAN CARLOS APACHE WELLNESS CENTER
Entity Type:Organization
Organization Name:SAN CARLOS APACHE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD SERVICES CLINICAL COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC
Authorized Official - Phone:928-475-4875
Mailing Address - Street 1:5 SAN CARLOS AVE.
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550
Mailing Address - Country:US
Mailing Address - Phone:928-475-4875
Mailing Address - Fax:
Practice Address - Street 1:5 SAN CARLOS AVE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550
Practice Address - Country:US
Practice Address - Phone:928-475-4875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA007411251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health