NPIMap

Organization Active NPI

Mogollon Treatment Center

Doing business as Mogollon Residential

  • Substance Abuse Rehabilitation Facility
  • Payson, AZ
National Provider Identifier
1063225233
Registry record updated Jan 30, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Substance Abuse Rehabilitation FacilityTaxonomy code 324500000X
Legal business name
MOGOLLON TREATMENT CENTER
Doing business as
Mogollon Residential
Practice address
212 W Wade LN
Payson, AZ 85541-4852
Phone
(928) 466-4242
Fax
(928) 474-7460
NPI assigned
Jan 30, 2025
Last updated
Jan 30, 2025By the provider in NPPES
Organization subpart
Yes

NPPES NPI Registry

Updated by the provider on Jan 30, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tyri Norman Blondal, LMSWNPI 1477316651
Title
Coo
Phone
(602) 516-2414

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Substance Abuse Rehabilitation Facility 324500000X NU Primary

Addresses

Primary practice location

212 W Wade LN
Payson, AZ 85541-4852

Mailing address

306 W Aero Dr
Payson, AZ 85541-5405
Phone (602) 516-2414

Other names 1

  • Mogollon Residential Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
03D2318161Mogollon Treatment Center Dba212 W Wade LN, Payson, AZ 85541Certificate of waiverFeb 5, 2027

National Provider Directory

National Provider Directory
Tax ID family
Mogollon Treatment Center6 organizations share this tax ID, including this one
Part of
Mogollon Treatment Center

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Locations

212 W Wade Ln
Payson, AZ 85541
Phone (928) 466-4242

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1738195200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1738195200000",
    "number": "1063225233",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "306 W AERO DR",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855415405",
            "telephone_number": "602-516-2414",
            "fax_number": "928-474-7460"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "212 W WADE LN",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855414852",
            "telephone_number": "928-466-4242",
            "fax_number": "928-474-7460"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOGOLLON TREATMENT CENTER",
        "organizational_subpart": "YES",
        "enumeration_date": "2025-01-30",
        "last_updated": "2025-01-30",
        "certification_date": "2025-01-30",
        "status": "A",
        "authorized_official_last_name": "BLONDAL",
        "authorized_official_first_name": "TYRI",
        "authorized_official_middle_name": "NORMAN",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "602-516-2414",
        "authorized_official_credential": "LMSW"
    },
    "taxonomies": [
        {
            "code": "324500000X",
            "taxonomy_group": "",
            "desc": "Substance Abuse Rehabilitation Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mogollon Residential",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Payson, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.