Provider Demographics
NPI:1376601914
Name:SEQUELCARE OF ARIZONA, LLC
Entity Type:Organization
Organization Name:SEQUELCARE OF ARIZONA, LLC
Other - Org Name:PRESCOTT OPC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-777-3280
Mailing Address - Street 1:3170 STILLWATER DR.
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305
Mailing Address - Country:US
Mailing Address - Phone:928-777-3280
Mailing Address - Fax:928-717-1660
Practice Address - Street 1:3170 STILLWATER DR.
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305
Practice Address - Country:US
Practice Address - Phone:928-777-3280
Practice Address - Fax:928-717-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2730101YM0800X
AZBH-3517101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ451604Medicaid
AZ157612OtherAHCCCS ID