Provider Demographics
NPI:1831245661
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 1:100 NORTH GILA BOULEVARD
Practice Address - Street 2:
Practice Address - City:GILA BEND
Practice Address - State:AZ
Practice Address - Zip Code:85227-2658
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 SVS HLTH SVS & MNTL HLTH ADM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-26
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ812851Medicaid
AZ030078Medicare Oscar/Certification
AZHSZ195Medicare ID - Type UnspecifiedPART B