Provider Demographics
NPI:1760906440
Name:EASTER SEALS BLAKE FOUNDATION
Entity Type:Organization
Organization Name:EASTER SEALS BLAKE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ARENDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-1529
Mailing Address - Street 1:7750 E BROADWAY BLVD STE A200
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3901
Mailing Address - Country:US
Mailing Address - Phone:520-327-1529
Mailing Address - Fax:520-327-1836
Practice Address - Street 1:310 S MEYER AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701-2207
Practice Address - Country:US
Practice Address - Phone:520-622-3933
Practice Address - Fax:520-670-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-03
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSL8349101YM0800X
251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty