Provider Demographics
NPI:1730375668
Name:EAGLEDANCER YOUTH AND FAMILY SERVICES, INC.
Entity type:Organization
Organization Name:EAGLEDANCER YOUTH AND FAMILY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HATCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-229-0560
Mailing Address - Street 1:1323 LOBO TRL
Mailing Address - Street 2:1323 LOBO TRAIL
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5407
Mailing Address - Country:US
Mailing Address - Phone:928-227-3950
Mailing Address - Fax:
Practice Address - Street 1:305 WEST BEN GAY
Practice Address - Street 2:
Practice Address - City:WHITE RIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-2312
Practice Address - Fax:928-338-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ320800000X, 324500000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ263967Medicaid