Provider Demographics
NPI:1831378793
Name:BANNER PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:BANNER PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 N HIGLEY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-1623
Practice Address - Country:US
Practice Address - Phone:480-543-2688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-29
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3057261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ279741Medicaid
Z118989Medicare PIN