Provider Demographics
NPI:1528400538
Name:EASTER SEALS BLAKE FOUNDATION
Entity Type:Organization
Organization Name:EASTER SEALS BLAKE FOUNDATION
Other - Org Name:BLAKE FOUNDATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ARENDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-1529
Mailing Address - Street 1:6420 E BROADWAY BLVD
Mailing Address - Street 2:SUITE B-200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3534
Mailing Address - Country:US
Mailing Address - Phone:520-207-7310
Mailing Address - Fax:520-795-4981
Practice Address - Street 1:1115 E FLORENCE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4228
Practice Address - Country:US
Practice Address - Phone:520-723-4429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-19
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
AZBH-4277251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH-4227OtherARIZONA DEPARTMENT OF HEALTH SERVICES - OFFICE OF BEHAVIORAL HEALTH LICENSURE