Provider Demographics
NPI:1831244169
Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Entity type:Organization
Organization Name:DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:(CEO) CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, MHA
Authorized Official - Phone:602-263-1567
Mailing Address - Street 1:PO BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1200
Mailing Address - Fax:602-263-1618
Practice Address - Street 1:2121 WEST RESERVATION LOOP ROAD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322
Practice Address - Country:US
Practice Address - Phone:602-263-1200
Practice Address - Fax:602-263-1618
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHEW IND HLTH SV HLTH SVS &M MNTL HLTH ADM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-25
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ812869Medicaid
AZTEZ084Medicare ID - Type UnspecifiedPART B
AZ030078Medicare Oscar/Certification