Provider Demographics
NPI:1578517108
Name:WEST YAVAPAI GUIDANCE CLINIC, INC.
Entity Type:Organization
Organization Name:WEST YAVAPAI GUIDANCE CLINIC, INC.
Other - Org Name:RUTH STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PLAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-445-5211
Mailing Address - Street 1:3343 N. WINGSONG DR.
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2283
Mailing Address - Country:US
Mailing Address - Phone:928-445-5211
Mailing Address - Fax:928-776-8484
Practice Address - Street 1:625 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-445-5211
Practice Address - Fax:928-776-8484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH1809261Q00000X
AZOTC6571261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WCHHDMedicare ID - Type Unspecified
WCHHDMedicare ID - Type Unspecified