Healthcare Provider Details

I. General information

NPI: 1477328623
Provider Name (Legal Business Name): GO DEHP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 N CENTRAL AVE FL 17
PHOENIX AZ
85012-1992
US

IV. Provider business mailing address

3800 N CENTRAL AVE FL 17
PHOENIX AZ
85012-1992
US

V. Phone/Fax

Practice location:
  • Phone: 480-225-0555
  • Fax:
Mailing address:
  • Phone: 480-225-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOSETTE SULLINS
Title or Position: CEO
Credential:
Phone: 480-225-0555