Provider Demographics
NPI:1053828160
Name:EASTER SEALS BLAKE FOUNDATION
Entity Type:Organization
Organization Name:EASTER SEALS BLAKE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ARENDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-1529
Mailing Address - Street 1:7750 E. BROADWAY BLVD
Mailing Address - Street 2:SUITE A-200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710
Mailing Address - Country:US
Mailing Address - Phone:520-327-1529
Mailing Address - Fax:520-327-1836
Practice Address - Street 1:709 N ALLRED LN SUITES 104-105
Practice Address - Street 2:
Practice Address - City:THATCHER
Practice Address - State:AZ
Practice Address - Zip Code:85552
Practice Address - Country:US
Practice Address - Phone:520-327-1529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X
AZOTC8598251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management