Healthcare Provider Details

I. General information

NPI: 1609420959
Provider Name (Legal Business Name): DENOVA COLLABORATIVE HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E THUNDERBIRD RD # 1-3
PHOENIX AZ
85022-5306
US

IV. Provider business mailing address

3101 N CENTRAL AVE STE 550
PHOENIX AZ
85012-2635
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-7373
  • Fax: 602-218-6383
Mailing address:
  • Phone: 602-230-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GRAHAM JOHNSON
Title or Position: CEO
Credential:
Phone: 602-230-7373