Provider Demographics
NPI:1528304367
Name:CATHOLIC CHARITIES COMMUNITY SERVICES
Entity type:Organization
Organization Name:CATHOLIC CHARITIES COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESOURCE SUPPORT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-864-7371
Mailing Address - Street 1:5151 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3224
Mailing Address - Country:US
Mailing Address - Phone:480-250-9157
Mailing Address - Fax:
Practice Address - Street 1:434 W GURLEY ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-3616
Practice Address - Country:US
Practice Address - Phone:928-778-2531
Practice Address - Fax:928-771-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3155251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ791924OtherAHCCCS 2013
AZ791924OtherAHCCCS 2013