Provider Demographics
NPI:1285647263
Name:VISIONQUEST NATIONAL LTD.
Entity Type:Organization
Organization Name:VISIONQUEST NATIONAL LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DERTOUZOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-486-2280
Mailing Address - Street 1:4400 E BROADWAY BLVD STE 501
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3554
Mailing Address - Country:US
Mailing Address - Phone:610-486-2280
Mailing Address - Fax:520-881-3269
Practice Address - Street 1:1010 CONCORD AVE STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-3366
Practice Address - Country:US
Practice Address - Phone:302-661-1826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA325980251S00000X
PA137430251S00000X
251S00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001477610-0045Medicaid
PA001477610-0055Medicaid
PA001477610-0063Medicaid