Provider Demographics
NPI:1740487222
Name:FAMILY SERVICE AGENCY
Entity type:Organization
Organization Name:FAMILY SERVICE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:520-721-1887
Mailing Address - Street 1:PO BOX 86537
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:520-721-0069
Practice Address - Street 1:1107 S GILBERT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5232
Practice Address - Country:US
Practice Address - Phone:602-264-9891
Practice Address - Fax:602-234-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
AZBH-1277251V00000X
AZOTC8084251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC11459OtherADHS/BMFL
AZ117079OtherAHCCCS