Provider Demographics
NPI:1821218801
Name:SAN CARLOS APACHE WELLNESS CENTER
Entity Type:Organization
Organization Name:SAN CARLOS APACHE WELLNESS CENTER
Other - Org Name:WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:DJANGI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:928-475-4875
Mailing Address - Street 1:5 SAN CARLOS BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550
Mailing Address - Country:US
Mailing Address - Phone:928-475-4875
Mailing Address - Fax:928-475-4880
Practice Address - Street 1:5 SAN CARLOS BOULEVARD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550
Practice Address - Country:US
Practice Address - Phone:928-475-4875
Practice Address - Fax:928-475-4880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty