Provider Demographics
NPI:1255663423
Name:COMMUNITY INTERVENTION ASSOCIATES, INC.
Entity Type:Organization
Organization Name:COMMUNITY INTERVENTION ASSOCIATES, INC.
Other - Org Name:COMMUNITY INTERVENTION ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:R
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-376-0026
Mailing Address - Street 1:2851 S AVENUE B BLDG 4
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7726
Mailing Address - Country:US
Mailing Address - Phone:928-376-0026
Mailing Address - Fax:928-782-2298
Practice Address - Street 1:1516 OCOTILLO AVENUE
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-0000
Practice Address - Country:US
Practice Address - Phone:928-669-5319
Practice Address - Fax:928-669-5368
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY INTERVENTION ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-12
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH3488251S00000X
AZBH-3994251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ750372Medicaid
AZ750372Medicaid