Lake Montezuma RTC, LLC

Primary specialty

Emotionally Disturbed Childrens' Residential Treatment FacilityTaxonomy code 322D00000X

License

BH4470 Issued in AZ

Legal business name

LAKE MONTEZUMA RTC, LLC

Doing business as

Sedona Sky Academy

Practice address

3090 Coronado Trail
Rimrock, AZ 86335-5283

Phone

(928) 567-1322

Fax

(928) 567-1323

NPI assigned

Apr 23, 2014

Last updated

Apr 23, 2014By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Tammy Behrmann

Title

Executive Director

Phone

(928) 567-1322

Specialties & licenses 1

Addresses

Other names 1

• Sedona Sky Academy Doing business as

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

{
    "created_epoch": "1398211200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1398211200000",
    "number": "1972923472",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3090 CORONADO TRAIL",
            "city": "RIMROCK",
            "state": "AZ",
            "postal_code": "863355283",
            "telephone_number": "928-567-1322",
            "fax_number": "928-567-1323"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3090 CORONADO TRAIL",
            "city": "RIMROCK",
            "state": "AZ",
            "postal_code": "863355283",
            "telephone_number": "928-567-1322",
            "fax_number": "928-567-1323"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE MONTEZUMA RTC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-23",
        "last_updated": "2014-04-23",
        "status": "A",
        "authorized_official_last_name": "BEHRMANN",
        "authorized_official_first_name": "TAMMY",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "928-567-1322"
    },
    "taxonomies": [
        {
            "code": "322D00000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Emotionally Disturbed Children",
            "state": "AZ",
            "license": "BH4470",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sedona Sky Academy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Kelly C Donohue, PHD
• Emoticare Rimrock LLC.
• Tamara Cy Garden, LPC
• Mark Gonchar, LASAC
• Clay Conrad Khin
• Katie McAndrew, SLPA
• Ingvild Mikkelborg, MA
• Montezuma Rimrock Fire District
• Timothy Mullins, MA
• Shelbi Lynn Labat Petrosius, LPC

• Emotionally Disturbed Childrens' Residential Treatment Facility in Rimrock, AZ
• Providers in Rimrock, AZ by specialty
• Emotionally Disturbed Childrens' Residential Treatment Facility in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 23, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.