Provider Demographics
NPI:1679809636
Name:SEQUELCARE OF ARIZONA
Entity Type:Organization
Organization Name:SEQUELCARE OF ARIZONA
Other - Org Name:TAP PROGRAM OUTPATIENT CLINIC - TEMPE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-777-3280
Mailing Address - Street 1:3170 STILLWATER DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305
Mailing Address - Country:US
Mailing Address - Phone:928-777-3280
Mailing Address - Fax:928-717-1660
Practice Address - Street 1:2020 S MCCLINTOCK DRIVE SUITE 105
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-284-7304
Practice Address - Fax:480-284-7616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3420251S00000X
AZOTC8667251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ476196Medicaid
AZBH-3420OtherAHCCCS
AZOTC8667OtherOUTPATIENT TREATMENT CENTER