Provider Demographics
NPI:1871672873
Name:CATHOLIC CHARITIES COMMUNITY SERVICES
Entity type:Organization
Organization Name:CATHOLIC CHARITIES COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIGID
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:928-607-3527
Mailing Address - Street 1:2101 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-4200
Mailing Address - Country:US
Mailing Address - Phone:928-774-9125
Mailing Address - Fax:
Practice Address - Street 1:1594 N OATMAN RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7308
Practice Address - Country:US
Practice Address - Phone:928-758-4176
Practice Address - Fax:928-758-5141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH1013251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ124185OtherAHCCCS