Provider Demographics
NPI:1356963839
Name:SUMMIT BEHAVIORAL HEALTH OF AZ, LLC
Entity type:Organization
Organization Name:SUMMIT BEHAVIORAL HEALTH OF AZ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ISENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-710-7021
Mailing Address - Street 1:8183 E FLORENTINE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-8481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1989 WILLOW LAKE RD UNIT 100-105
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-4885
Practice Address - Country:US
Practice Address - Phone:928-756-0694
Practice Address - Fax:928-708-9620
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT BEHAVIORAL HEALTH OF AZ, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility