Provider Demographics
NPI:1932349644
Name:NORTHERN ARIZONA SUBSTANCE ABUSE SERVICES
Entity type:Organization
Organization Name:NORTHERN ARIZONA SUBSTANCE ABUSE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:ERHART
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LISAC, CCDVC,
Authorized Official - Phone:928-773-9376
Mailing Address - Street 1:2101 N 4TH ST STE 215
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-4200
Mailing Address - Country:US
Mailing Address - Phone:928-773-9376
Mailing Address - Fax:
Practice Address - Street 1:2101 N 4TH ST STE 215
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-4200
Practice Address - Country:US
Practice Address - Phone:928-773-9376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ#BH-1634251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ597908OtherAHCCCS