Provider Demographics
NPI:1609105642
Name:AZ CENTER FOR CHANGE
Entity Type:Organization
Organization Name:AZ CENTER FOR CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GENCO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:602-253-8488
Mailing Address - Street 1:4205 N 7TH AVE
Mailing Address - Street 2:311
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3078
Mailing Address - Country:US
Mailing Address - Phone:602-253-8488
Mailing Address - Fax:602-253-8340
Practice Address - Street 1:4205 N 7TH AVE
Practice Address - Street 2:311
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3078
Practice Address - Country:US
Practice Address - Phone:602-253-8488
Practice Address - Fax:602-253-8340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3486251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health