Provider Demographics
NPI:1497852768
Name:THE DEVEREUX FOUNDATION
Entity Type:Organization
Organization Name:THE DEVEREUX FOUNDATION
Other - Org Name:DEVEREUX ARIZONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN-BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-998-2920
Mailing Address - Street 1:11000 N SCOTTSDALE RD STE 260
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5270
Mailing Address - Country:US
Mailing Address - Phone:480-998-2920
Mailing Address - Fax:480-443-5587
Practice Address - Street 1:6436 E SWEETWATER AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-4581
Practice Address - Country:US
Practice Address - Phone:480-998-2920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-246322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ599904OtherAHCCCS ID