Provider Demographics
NPI:1700377983
Name:PRONGHORN PSYCHIATRY
Entity type:Organization
Organization Name:PRONGHORN PSYCHIATRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LETENDRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-583-7799
Mailing Address - Street 1:5940 E. COPPER HILL DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314
Mailing Address - Country:US
Mailing Address - Phone:928-583-7799
Mailing Address - Fax:928-583-7891
Practice Address - Street 1:5940 E. COPPER HILL DR
Practice Address - Street 2:SUITE E
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-583-7799
Practice Address - Fax:928-583-7891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-23
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
AZOTC8169261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No291U00000XLaboratoriesClinical Medical Laboratory