Provider Demographics
NPI: | 1376275339 |
---|---|
Name: | RECOVIA LLC ESTRELLA |
Entity Type: | Organization |
Organization Name: | RECOVIA LLC ESTRELLA |
Other - Org Name: | RECOVIA ESTRELLA |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DIRECTOR OF BILLING |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | CINDY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | PROFFITT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | CPC,CPB, EMT-P |
Authorized Official - Phone: | 480-219-7178 |
Mailing Address - Street 1: | PO BOX 20216 |
Mailing Address - Street 2: | |
Mailing Address - City: | PHOENIX |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85036-0216 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 480-219-7178 |
Mailing Address - Fax: | 480-219-8138 |
Practice Address - Street 1: | 9250 W THOMAS RD STE 250 |
Practice Address - Street 2: | |
Practice Address - City: | PHOENIX |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85037-3362 |
Practice Address - Country: | US |
Practice Address - Phone: | 480-219-7178 |
Practice Address - Fax: | 480-219-7138 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-06-28 |
Last Update Date: | 2022-10-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Single Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Single Specialty |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Single Specialty |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Single Specialty |
No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Single Specialty |
No | 163WA0400X | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | Group - Single Specialty |
No | 251S00000X | Agencies | Community/Behavioral Health | ||
No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | ||
No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
1427421098 | Other | PROVIDER TYPE 77 |