Provider Demographics
NPI:1811382021
Name:CIRCLE THE CITY BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:CIRCLE THE CITY BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-776-9000
Mailing Address - Street 1:333 W INDIAN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3205
Mailing Address - Country:US
Mailing Address - Phone:602-776-9000
Mailing Address - Fax:
Practice Address - Street 1:333 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3205
Practice Address - Country:US
Practice Address - Phone:602-776-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIRCLE THE CITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-03
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZUNC5520261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ012453Medicaid