Provider Demographics
NPI:1548691454
Name:EASTER SEALS BLAKE FOUNDATION
Entity type:Organization
Organization Name:EASTER SEALS BLAKE FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
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:STE. A200
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3901
Mailing Address - Country:US
Mailing Address - Phone:520-327-1529
Mailing Address - Fax:520-327-1836
Practice Address - Street 1:4454 E 3RD ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1189
Practice Address - Country:US
Practice Address - Phone:520-881-3090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-4429320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ881725OtherAHCCCS PROVIDER
AZBH4429OtherAZ BEHAVIORAL HEALTH RESIDENTIAL FACILITY LICENSE