Provider Demographics
NPI:1053490052
Name:CATHOLIC CHARITIES COMMUNITY SERVICES, INC
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES COMMUNITY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESOURCE SUPPORT SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-864-7371
Mailing Address - Street 1:5151 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3224
Mailing Address - Country:US
Mailing Address - Phone:480-250-9157
Mailing Address - Fax:
Practice Address - Street 1:434 W GURLEY STREET
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-778-2531
Practice Address - Fax:928-771-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH316251S00000X
AZOTC5874251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ442265OtherAHCCCS