Provider Demographics
NPI:1275978900
Name:COPPER CANYON ACADEMY
Entity Type:Organization
Organization Name:COPPER CANYON ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ARIELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LAC
Authorized Official - Phone:928-567-1322
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:RIMROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:86335-0230
Mailing Address - Country:US
Mailing Address - Phone:928-567-1322
Mailing Address - Fax:
Practice Address - Street 1:3095 CORONADO TRAIL
Practice Address - Street 2:
Practice Address - City:LAKE MONTEZUMA
Practice Address - State:AZ
Practice Address - Zip Code:86335
Practice Address - Country:US
Practice Address - Phone:928-567-1322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLAC-13769OtherAZ BOARD OF BEHAVIORAL HEALTH EXAMINERS