Healthcare Provider Details

I. General information

NPI: 1871200907
Provider Name (Legal Business Name): COREBELLA HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 W OLIVE AVE STE 106
GLENDALE AZ
85302-3147
US

IV. Provider business mailing address

4600 MONTGOMERY RD STE 400
CINCINNATI OH
45212-2600
US

V. Phone/Fax

Practice location:
  • Phone: 480-409-0322
  • Fax: 877-559-2816
Mailing address:
  • Phone: 833-510-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAD SMITH
Title or Position: CEO
Credential:
Phone: 833-510-4357