Provider Demographics
NPI:1245523364
Name:COMMUNITY INTERVENTION ASSOCIATES
Entity type:Organization
Organization Name:COMMUNITY INTERVENTION ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:R
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-376-0026
Mailing Address - Street 1:2851 S AVE B
Mailing Address - Street 2:BLDG 4
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:928-376-0026
Mailing Address - Fax:928-782-2298
Practice Address - Street 1:1701 NORTH DOUGLASAVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607
Practice Address - Country:US
Practice Address - Phone:520-727-7091
Practice Address - Fax:520-364-2770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3769251S00000X
AZBH-3221251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ881988Medicaid
AZ620627Medicaid
AZ620627Medicaid
AZ881988Medicaid