Provider Demographics
NPI:1780788240
Name:PASADERA BEHAVIORAL HEALTH NETWORK DBA LEVEL II DETOXIFICATION
Entity type:Organization
Organization Name:PASADERA BEHAVIORAL HEALTH NETWORK DBA LEVEL II DETOXIFICATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF QM
Authorized Official - Prefix:
Authorized Official - First Name:GROVER
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LISAC, CPHQ
Authorized Official - Phone:520-618-8622
Mailing Address - Street 1:2502 N. DODGE BLVD.
Mailing Address - Street 2:SUITE 190
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2675
Mailing Address - Country:US
Mailing Address - Phone:520-618-8622
Mailing Address - Fax:520-617-1608
Practice Address - Street 1:2950 N. DODGE BLVD.
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2012
Practice Address - Country:US
Practice Address - Phone:520-628-3155
Practice Address - Fax:520-628-3158
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMPASS BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-12
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
324500000X
AZBH/H-3958324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ592578Medicaid
AZ807745Medicaid
AZBH/H-3958OtherSTATE LICENSE