Provider Demographics
NPI:1205070786
Name:COPPER CANYON ACADEMY
Entity type:Organization
Organization Name:COPPER CANYON ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-567-1322
Mailing Address - Street 1:PO BOX 230
Mailing Address - Street 2:
Mailing Address - City:RIMROCK
Mailing Address - State:AZ
Mailing Address - Zip Code:86335
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
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:2009-04-28
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
AZBH-22402084P0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty