Provider Demographics
NPI:1790267011
Name:PSA BEHAVIORAL HEALTH AGENCY
Entity Type:Organization
Organization Name:PSA BEHAVIORAL HEALTH AGENCY
Other - Org Name:RESILIENT HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-995-1767
Mailing Address - Street 1:2255 W NORTHERN AVE STE B100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4936
Mailing Address - Country:US
Mailing Address - Phone:602-995-1767
Mailing Address - Fax:602-995-1863
Practice Address - Street 1:1415 N 1ST ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1604
Practice Address - Country:US
Practice Address - Phone:602-595-5447
Practice Address - Fax:602-595-4537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-04
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC9095251K00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ091528Medicaid