Provider Demographics
NPI:1972783355
Name:THE WICK HOME FOR EMOTIONAL GROWTH AND RECOVERY
Entity type:Organization
Organization Name:THE WICK HOME FOR EMOTIONAL GROWTH AND RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBLATT
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:928-639-9425
Mailing Address - Street 1:2102 E FIR ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326
Mailing Address - Country:US
Mailing Address - Phone:928-639-9425
Mailing Address - Fax:928-639-1484
Practice Address - Street 1:2102 E FIR ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326
Practice Address - Country:US
Practice Address - Phone:928-639-9425
Practice Address - Fax:928-639-1484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children