Provider Demographics
NPI:1790773620
Name:SOUTHEASTERN ARIZONA BEHAVIORAL HEALTH SERVICE, INC.
Entity Type:Organization
Organization Name:SOUTHEASTERN ARIZONA BEHAVIORAL HEALTH SERVICE, INC.
Other - Org Name:SEABHS WILLCOX OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTRACTS & CREDENTIALING ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:ESTELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-838-5513
Mailing Address - Street 1:611 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-6718
Mailing Address - Country:US
Mailing Address - Phone:520-586-0800
Mailing Address - Fax:520-586-0116
Practice Address - Street 1:404 W REX ALLEN DR
Practice Address - Street 2:
Practice Address - City:WILLCOX
Practice Address - State:AZ
Practice Address - Zip Code:85643-1120
Practice Address - Country:US
Practice Address - Phone:520-384-2521
Practice Address - Fax:520-384-0543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2672251K00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ082893Medicaid
AZOTC-6143OtherADHS LICENSING