Provider Demographics
NPI:1295965531
Name:WILLIAMS SUDAN GUEST HOMES
Entity type:Organization
Organization Name:WILLIAMS SUDAN GUEST HOMES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLLLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-751-7483
Mailing Address - Street 1:4133 EAST GLENAGELE DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-7423
Mailing Address - Country:US
Mailing Address - Phone:480-751-7483
Mailing Address - Fax:480-895-8399
Practice Address - Street 1:15111 E VIA DE OLIVOS RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-7423
Practice Address - Country:US
Practice Address - Phone:480-751-7483
Practice Address - Fax:480-895-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3215251C00000X, 251S00000X, 261QM0850X, 261QP2000X, 261QR0405X, 261QX0100X, 320800000X, 3245S0500X, 347C00000X, 320900000X
AZBBH-3215261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ438547Medicaid