Provider Demographics
NPI:1992136808
Name:EASTER SEALS BLAKE FOUNDATION
Entity type:Organization
Organization Name:EASTER SEALS BLAKE FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ARENDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-1529
Mailing Address - Street 1:7750 E BROADWAY BLVD
Mailing Address - Street 2:STE. A200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3901
Mailing Address - Country:US
Mailing Address - Phone:520-327-1529
Mailing Address - Fax:520-327-1836
Practice Address - Street 1:3327 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-5858
Practice Address - Country:US
Practice Address - Phone:520-318-0272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4428320800000X
AZBH-4428322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH4428OtherAZ BEHAVIORAL HEALTH RESIDENTIAL FACILITY LICENSE
AZ881681OtherAHCCCS PROVIDER