Provider Demographics
NPI:1194027847
Name:SAN TAN BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:SAN TAN BEHAVIORAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:480-507-3644
Mailing Address - Street 1:2451 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2471
Mailing Address - Country:US
Mailing Address - Phone:480-507-3644
Mailing Address - Fax:480-632-0026
Practice Address - Street 1:655 SOUTHLAKE RD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6768
Practice Address - Country:US
Practice Address - Phone:928-358-1087
Practice Address - Fax:480-632-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3755343900000X, 385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ308968OtherAHCCCS