Provider Demographics
NPI:1306021126
Name:DESERT EDGE MENTORING SERVICES
Entity Type:Organization
Organization Name:DESERT EDGE MENTORING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-237-2485
Mailing Address - Street 1:PO BOX 1097
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-1097
Mailing Address - Country:US
Mailing Address - Phone:602-237-2485
Mailing Address - Fax:602-274-6531
Practice Address - Street 1:1950 W HEATHERBRAE DR
Practice Address - Street 2:STE 10
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5110
Practice Address - Country:US
Practice Address - Phone:602-237-2485
Practice Address - Fax:602-274-6531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3807251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health