Provider Demographics
NPI:1548356207
Name:EASTER SEALS BLAKE FOUNDATION
Entity type:Organization
Organization Name:EASTER SEALS BLAKE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
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:SUITE A200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710
Mailing Address - Country:US
Mailing Address - Phone:520-327-1529
Mailing Address - Fax:520-327-1836
Practice Address - Street 1:7750 E BROADWAY BLVD
Practice Address - Street 2:SUITE A200
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710
Practice Address - Country:US
Practice Address - Phone:520-327-1529
Practice Address - Fax:520-327-1836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ042622Medicaid