Organization
TEEN OUT REACH SERVICES
Active
Parent organization
BANNER HEALTH
Other names
Teen Out Reach Services
Organization subpart
Yes
Provider details
NPI number
Legal business name
BANNER HEALTH
Authorized official
AMANDA REANE JOHNSON MD (DIRECTOR)
(480) 696-0338
Entity
Organization
Contact information
Practice address
544 S 96TH PL, MESA, AZ 85208-2512
(480) 696-0338
Mailing address
544 S 96TH PL APT 2080, MESA, AZ 85208-2512
(480) 696-0338
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
282NC0060X
Critical Access Hospital
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
282NC0060X
—
AZ
Enumeration date
03/10/2021
Last updated
06/03/2021
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