Provider Demographics
NPI:1205842705
Name:PANTANO BEHAVIORAL HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:PANTANO BEHAVIORAL HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ARENDT
Authorized Official - Suffix:
Authorized Official - Credentials:CFE
Authorized Official - Phone:520-623-9833
Mailing Address - Street 1:5055 E BROADWAY BLVD STE C104
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3641
Mailing Address - Country:US
Mailing Address - Phone:520-623-9833
Mailing Address - Fax:520-623-9083
Practice Address - Street 1:5055 E BROADWAY BLVD STE C104
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3641
Practice Address - Country:US
Practice Address - Phone:520-623-9833
Practice Address - Fax:520-623-9083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2183261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ772576OtherAHCCCS ID