Healthcare Provider Details

I. General information

NPI: 1033971742
Provider Name (Legal Business Name): NEW DESTINY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5251 W CAMPBELL AVE STE 204
PHOENIX AZ
85031-1719
US

IV. Provider business mailing address

5251 W CAMPBELL AVE STE 204
PHOENIX AZ
85031-1719
US

V. Phone/Fax

Practice location:
  • Phone: 480-258-8703
  • Fax:
Mailing address:
  • Phone: 408-791-4817
  • Fax:

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. BILL ETIENNE WILSON
Title or Position: CEO
Credential:
Phone: 408-791-4817