Provider Demographics
NPI:1578258851
Name:TERRA NOVA BEHAVIORAL HEALTHCARE LLC
Entity Type:Organization
Organization Name:TERRA NOVA BEHAVIORAL HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:MARINELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-642-3030
Mailing Address - Street 1:PO BOX 13146
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-3146
Mailing Address - Country:US
Mailing Address - Phone:928-642-3030
Mailing Address - Fax:
Practice Address - Street 1:545 S LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-7655
Practice Address - Country:US
Practice Address - Phone:928-642-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH8369OtherBEHAVIORAL HEALTH RESIDENTIAL FACILITY