Provider Demographics
NPI:1689800013
Name:DHHS, IHS, PHOENIX AREA, NEVADA SKIES YOUTH
Entity Type:Organization
Organization Name:DHHS, IHS, PHOENIX AREA, NEVADA SKIES YOUTH
Other - Org Name:NEVADA SKIES YOUTH WELLNESS CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MS
Authorized Official - Phone:520-562-4205
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:104 BIG BEND RANCH ROAD
Mailing Address - City:WADSWORTH
Mailing Address - State:NV
Mailing Address - Zip Code:89442
Mailing Address - Country:US
Mailing Address - Phone:775-352-6840
Mailing Address - Fax:775-575-3180
Practice Address - Street 1:104 BIG BEND RANCH ROAD
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:NV
Practice Address - Zip Code:89442
Practice Address - Country:US
Practice Address - Phone:775-352-6840
Practice Address - Fax:775-575-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVN/A324500000X, 3245S0500X
2757893245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ727370Medicaid