Provider Demographics
NPI:1902092166
Name:CODAC BEHAVIORAL HEALTH SERVICES OF PIMA COUNTY, INC.
Entity Type:Organization
Organization Name:CODAC BEHAVIORAL HEALTH SERVICES OF PIMA COUNTY, INC.
Other - Org Name:CHILDREN & ADOLESCENT SERVICES (CAS)
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:W
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-327-4505
Mailing Address - Street 1:127 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-2005
Mailing Address - Country:US
Mailing Address - Phone:520-327-4505
Mailing Address - Fax:520-202-1889
Practice Address - Street 1:160 W FORT LOWELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-3812
Practice Address - Country:US
Practice Address - Phone:520-318-3266
Practice Address - Fax:520-318-0821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-2093261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ278824Medicaid
AZ278824Medicaid