Provider Demographics
NPI:1841636776
Name:SAN PEDRO HEALTH
Entity type:Organization
Organization Name:SAN PEDRO HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-515-9610
Mailing Address - Street 1:4151 LA LINDA WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-4600
Mailing Address - Country:US
Mailing Address - Phone:520-515-9610
Mailing Address - Fax:
Practice Address - Street 1:4151 LA LINDA WAY STE 102
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-4600
Practice Address - Country:US
Practice Address - Phone:520-515-9610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-19
Last Update Date:2013-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAMFT-10301251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health