Provider Demographics
NPI:1902974934
Name:COTTONWOOD DE TUCSON, INC
Entity Type:Organization
Organization Name:COTTONWOOD DE TUCSON, INC
Other - Org Name:COTTONWOOD DE TUCSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-743-0411
Mailing Address - Street 1:4110 W SWEETWATER DR
Mailing Address - Street 2:BLDG 1400
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-9348
Mailing Address - Country:US
Mailing Address - Phone:520-743-0411
Mailing Address - Fax:520-743-7991
Practice Address - Street 1:4110 W SWEETWATER DR
Practice Address - Street 2:BLDG 1400
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-9348
Practice Address - Country:US
Practice Address - Phone:520-743-0411
Practice Address - Fax:520-743-7991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ283Q00000X, 324500000X, 3245S0500X
AZBH-073283Q00000X, 324500000X, 3245S0500X
AZIFBH6377283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH073OtherAZ DEPT OF HEALTH SERVICE