MEDICARE: A NEW LEAF

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	OTC6465	AZ
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OTC6465	OTHER	AZ	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013349570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A NEW LEAF

Provider Business Mailing Address
First Line	:	868 E UNIVERSITY DR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85203-8033
Country	:	US
Telephone Number	:	480-969-4024
Fax Number	:	480-969-0039

Provider Business Practice Location Address
First Line	:	8581 N 61ST AVE BLDG A
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85302-5493
Country	:	US
Telephone Number	:	623-934-1991
Fax Number	:	623-878-9335

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	GRACIA DANIS
Credential	:
Telephone Number	:	520-591-5394

Provider Enumeration Date	:	08/06/2013
Last Update Date	:	07/31/2024

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Directions to “A NEW LEAF ” Practice Location

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