Provider Demographics
NPI:1457746497
Name:PASADERA BEHAVIORAL HEALTH NETWORK, INC.
Entity Type:Organization
Organization Name:PASADERA BEHAVIORAL HEALTH NETWORK, INC.
Other - Org Name:DODGE DETOXIFICATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF QUALITY MANAGEMENT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, RMM, ICD10CT-CM
Authorized Official - Phone:520-628-3400
Mailing Address - Street 1:2700 S 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-4730
Mailing Address - Country:US
Mailing Address - Phone:520-628-3400
Mailing Address - Fax:520-628-3401
Practice Address - Street 1:2502 N DODGE BLVD
Practice Address - Street 2:SUITE 190
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2671
Practice Address - Country:US
Practice Address - Phone:520-618-8600
Practice Address - Fax:520-617-1608
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PASADERA BEHAVIORAL HEALTH NETWORK, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-06
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZIFBH7082276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ019108Medicaid
AZIFBH7082OtherSTATE LICENSE