Provider Demographics
NPI:1770195612
Name:CTB AZ, LLC
Entity type:Organization
Organization Name:CTB AZ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MASENGALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-318-2041
Mailing Address - Street 1:2401 W SOUTHERN AVE LOT 462
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4342
Mailing Address - Country:US
Mailing Address - Phone:602-318-2041
Mailing Address - Fax:
Practice Address - Street 1:2075 S COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-3040
Practice Address - Country:US
Practice Address - Phone:602-318-2041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, ChildGroup - Single Specialty