Provider Demographics
NPI:1982289062
Name:TEEN OUT REACH SERVICES
Entity Type:Organization
Organization Name:TEEN OUT REACH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:REANE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-696-0338
Mailing Address - Street 1:544 S 96TH PL APT 2080
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-2512
Mailing Address - Country:US
Mailing Address - Phone:480-696-0338
Mailing Address - Fax:
Practice Address - Street 1:544 S 96TH PL
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-2512
Practice Address - Country:US
Practice Address - Phone:480-696-0338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-10
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No282NC0060XHospitalsGeneral Acute Care HospitalCritical AccessGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ282NC0060XMedicaid