Provider Demographics
NPI:1801377270
Name:TREATMENT ASSESSMENT SCREENING CENTER, INC
Entity Type:Organization
Organization Name:TREATMENT ASSESSMENT SCREENING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PROGRAM OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LATRICE
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-254-7328
Mailing Address - Street 1:4016 N BLACK CANYON HWY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-4730
Mailing Address - Country:US
Mailing Address - Phone:602-254-7328
Mailing Address - Fax:602-255-0851
Practice Address - Street 1:2314 N 4TH ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-3709
Practice Address - Country:US
Practice Address - Phone:928-526-5417
Practice Address - Fax:928-526-5615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC9085251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC9085OtherARIZONA DEPARTMENT OF HEALTH SERVICES OUTPATIENT TREATMENT CENTER LICENSE