Provider Demographics
NPI:1558483677
Name:TUBA CITY OUTPATIENT TREATMENT CENTER
Entity Type:Organization
Organization Name:TUBA CITY OUTPATIENT TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MED, LPC
Authorized Official - Phone:928-657-8000
Mailing Address - Street 1:PO BOX 1350
Mailing Address - Street 2:BLDG. 25 MAIN STREET
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-1350
Mailing Address - Country:US
Mailing Address - Phone:928-283-3346
Mailing Address - Fax:928-283-3039
Practice Address - Street 1:MAIN STREET BLDG. 25
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-1350
Practice Address - Country:US
Practice Address - Phone:928-283-3346
Practice Address - Fax:928-283-3039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ329492Medicaid