Healthcare Provider Details

I. General information

NPI: 1013349570
Provider Name (Legal Business Name): A NEW LEAF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8581 N 61ST AVE BLDG A
GLENDALE AZ
85302-5493
US

IV. Provider business mailing address

868 E UNIVERSITY DR
MESA AZ
85203-8033
US

V. Phone/Fax

Practice location:
  • Phone: 623-934-1991
  • Fax: 623-878-9335
Mailing address:
  • Phone: 480-969-4024
  • Fax: 480-969-0039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberOTC6465
License Number StateAZ

VIII. Authorized Official

Name: GRACIA DANIS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 520-591-5394