Provider Demographics
NPI:1336310275
Name:SPRINGBROOK HABILITATION SERVICES, LLC
Entity Type:Organization
Organization Name:SPRINGBROOK HABILITATION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MED
Authorized Official - Phone:602-424-1838
Mailing Address - Street 1:4835 E CACTUS RD
Mailing Address - Street 2:SUITE # 460
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4191
Mailing Address - Country:US
Mailing Address - Phone:602-424-1838
Mailing Address - Fax:602-424-7879
Practice Address - Street 1:3843 E LARKSPUR DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7345
Practice Address - Country:US
Practice Address - Phone:602-595-3025
Practice Address - Fax:602-595-6029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2586320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ701418Medicaid