Provider Demographics
NPI:1912178997
Name:PASCUA YAQUI TRIBE
Entity Type:Organization
Organization Name:PASCUA YAQUI TRIBE
Other - Org Name:PASCUA YAQUI TRIBE CENTERED SPIRIT PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BEHAVIORAL HEALTH
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:YBANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LISAC
Authorized Official - Phone:520-879-6060
Mailing Address - Street 1:7490 S CAMINO DE OESTE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-9308
Mailing Address - Country:US
Mailing Address - Phone:520-879-6060
Mailing Address - Fax:520-879-6099
Practice Address - Street 1:9405 S AVENIDA DEL YAQUI
Practice Address - Street 2:
Practice Address - City:GUADALUPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2529
Practice Address - Country:US
Practice Address - Phone:480-768-2021
Practice Address - Fax:480-768-2053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PASCUA YAQUI TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2283251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ925422OtherAHCCCS CLINIC ID NUMBER