Provider Demographics
NPI:1083835458
Name:KAIBETO OUTPATIENT TREATMENT CENTER
Entity Type:Organization
Organization Name:KAIBETO OUTPATIENT TREATMENT CENTER
Other - Org Name:NAVAJO NATION
Other - Org Type:Other Name
Authorized Official - Title/Position:BEHAVIORAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MED, LPC
Authorized Official - Phone:928-673-3267
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:KAIBETO
Mailing Address - State:AZ
Mailing Address - Zip Code:86053-2147
Mailing Address - Country:US
Mailing Address - Phone:928-673-3267
Mailing Address - Fax:928-673-3269
Practice Address - Street 1:0.5 MILE SOUTH OF KAIBETO MARKET
Practice Address - Street 2:
Practice Address - City:KAIBETO
Practice Address - State:AZ
Practice Address - Zip Code:86053-2147
Practice Address - Country:US
Practice Address - Phone:928-673-3267
Practice Address - Fax:928-673-3269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ822909101YA0400X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ822909Medicaid