Provider Demographics
NPI:1124407390
Name:SEQUELCARE OF ARIZONA, LLC
Entity Type:Organization
Organization Name:SEQUELCARE OF ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HCTC PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-777-3280
Mailing Address - Street 1:3656 PACKSADDLE RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8603 E EASTRIDGE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-8562
Practice Address - Country:US
Practice Address - Phone:928-777-3280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ467011103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty