Provider Demographics
NPI:1972923472
Name:LAKE MONTEZUMA RTC, LLC
Entity Type:Organization
Organization Name:LAKE MONTEZUMA RTC, LLC
Other - Org Name:SEDONA SKY ACADEMY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEHRMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-567-1322
Mailing Address - Street 1:3090 CORONADO TRAIL
Mailing Address - Street 2:
Mailing Address - City:RIMROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:86335-5283
Mailing Address - Country:US
Mailing Address - Phone:928-567-1322
Mailing Address - Fax:928-567-1323
Practice Address - Street 1:3090 CORONADO TRAIL
Practice Address - Street 2:
Practice Address - City:RIMROCK
Practice Address - State:AZ
Practice Address - Zip Code:86335-5283
Practice Address - Country:US
Practice Address - Phone:928-567-1322
Practice Address - Fax:928-567-1323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4470322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children