Provider Demographics
NPI:1578033809
Name:SOUTH EASTERN ARIZONA BEHAVIORAL HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:SOUTH EASTERN ARIZONA BEHAVIORAL HEALTH SERVICES, INC.
Other - Org Name:DOUGLAS INTEGRATED COUNSELING CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTS & CREDENTIALING ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:ESTELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-838-5513
Mailing Address - Street 1:611 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-6718
Mailing Address - Country:US
Mailing Address - Phone:520-586-0800
Mailing Address - Fax:520-586-0855
Practice Address - Street 1:1100 N F AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607-1919
Practice Address - Country:US
Practice Address - Phone:520-364-3630
Practice Address - Fax:520-586-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-29
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ478436Medicaid
AZOTC-9263OtherADHS LICENSING