Provider Demographics
NPI:1740641612
Name:SCOTTSDALE PROVIDENCE RECOVERY CENTER
Entity type:Organization
Organization Name:SCOTTSDALE PROVIDENCE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:480-284-7440
Mailing Address - Street 1:8889 E VIA LINDA
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5420
Mailing Address - Country:US
Mailing Address - Phone:480-284-7440
Mailing Address - Fax:480-284-4178
Practice Address - Street 1:8889 E VIA LINDA
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5420
Practice Address - Country:US
Practice Address - Phone:480-284-7440
Practice Address - Fax:480-284-4178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4837101YA0400X, 101YM0800X, 1041C0700X, 261QM0850X, 261QM1300X, 261QR0405X, 320800000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility