Provider Demographics
NPI:1821705104
Name:SCOTTSDALE PROVIDENCE RECOVERY CENTER
Entity Type:Organization
Organization Name:SCOTTSDALE PROVIDENCE RECOVERY CENTER
Other - Org Name:SCOTTSDALE PROVIDENCE RESIDENTIAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:602-448-4055
Mailing Address - Street 1:8889 E VIA LINDA
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5420
Mailing Address - Country:US
Mailing Address - Phone:480-284-7440
Mailing Address - Fax:480-284-4178
Practice Address - Street 1:9389 E VIA DEL SOL DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-5072
Practice Address - Country:US
Practice Address - Phone:480-284-7440
Practice Address - Fax:480-284-4178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCOTTSDALE PROVIDENCE RECOVERY CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-04
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH8061OtherADHS LICENSE