Provider Demographics
NPI:1417468398
Name:PARADISE VALLEY BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:PARADISE VALLEY BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-400-2288
Mailing Address - Street 1:3015 E GELDING DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-5032
Mailing Address - Country:US
Mailing Address - Phone:602-400-2288
Mailing Address - Fax:
Practice Address - Street 1:13401 N 30TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-6028
Practice Address - Country:US
Practice Address - Phone:602-400-2288
Practice Address - Fax:602-996-1577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARADISE VALLEY BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARBH5158320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH5158OtherDEPARTMENT OF BEHAVIORAL HEALTH