Provider Demographics
NPI:1811109762
Name:KAYENTA OUTPATIENT TREATMENT CENTER
Entity type:Organization
Organization Name:KAYENTA OUTPATIENT TREATMENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLATCHFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:928-697-5570
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-0487
Mailing Address - Country:US
Mailing Address - Phone:928-697-5570
Mailing Address - Fax:928-697-5574
Practice Address - Street 1:HWY 394.3 US-160
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033-0487
Practice Address - Country:US
Practice Address - Phone:928-697-5570
Practice Address - Fax:928-697-5574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ329559Medicaid