Provider Demographics
NPI:1326217308
Name:FLORENCE CRITTENTON SERVICES OF ARIZONA, INC.
Entity Type:Organization
Organization Name:FLORENCE CRITTENTON SERVICES OF ARIZONA, INC.
Other - Org Name:FCS THERAPEUTIC GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:602-274-7318
Mailing Address - Street 1:715 W MARIPOSA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2449
Mailing Address - Country:US
Mailing Address - Phone:602-274-7318
Mailing Address - Fax:602-274-7549
Practice Address - Street 1:715 W MARIPOSA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2449
Practice Address - Country:US
Practice Address - Phone:602-274-7318
Practice Address - Fax:602-274-7549
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORENCE CRITTENTON SERVICES OF ARIZONA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-25
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2133322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ747058Medicaid