Provider Demographics
NPI:1104929504
Name:PRISMA COMMUNITY CARE
Entity type:Organization
Organization Name:PRISMA COMMUNITY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-307-5330
Mailing Address - Street 1:1101 N CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1844
Mailing Address - Country:US
Mailing Address - Phone:602-347-0873
Mailing Address - Fax:602-246-1980
Practice Address - Street 1:1101 N. CENTRAL AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004
Practice Address - Country:US
Practice Address - Phone:602-307-5330
Practice Address - Fax:602-307-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X, 103TC1900X, 251K00000X, 163W00000X
BH2474251K00000X
AZBH4322251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or WelfareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ928418Medicaid
AZ928418Medicaid