Provider Demographics
NPI: | 1487635389 |
---|---|
Name: | SPECTRUM HEALTHCARE GROUP, INC. |
Entity Type: | Organization |
Organization Name: | SPECTRUM HEALTHCARE GROUP, INC. |
Other - Org Name: | VERDE VALLEY GUIDANCE CLINIC |
Other - Org Type: | Former Legal Business Name |
Authorized Official - Title/Position: | CREDENTIALING SPECIALIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CORINNE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BAILEY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 928-634-2236 |
Mailing Address - Street 1: | 8 E COTTONWOOD ST |
Mailing Address - Street 2: | |
Mailing Address - City: | COTTONWOOD |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 86326-4382 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 928-634-2236 |
Mailing Address - Fax: | 928-634-8960 |
Practice Address - Street 1: | 8 E COTTONWOOD ST BLDG A |
Practice Address - Street 2: | |
Practice Address - City: | COTTONWOOD |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 86326-6237 |
Practice Address - Country: | US |
Practice Address - Phone: | 877-634-7333 |
Practice Address - Fax: | 866-984-3891 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-11-08 |
Last Update Date: | 2023-09-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
101YM0800X, 101YP2500X, 1041C0700X, 163W00000X, 171M00000X, 207Q00000X, 207R00000X, 208000000X, 2084A0401X, 2084P0800X, 208VP0000X, 363A00000X, 363L00000X, 363LP0808X | ||
AZ | BH1466 | 261QM0801X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 163W00000X | Nursing Service Providers | Registered Nurse | Group - Multi-Specialty | |
No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 057952 | Medicaid | |
AZ | ZWMBQF | Other | MEDICARE ID# |