Healthcare Provider Details

I. General information

NPI: 1285346536
Provider Name (Legal Business Name): CHOLLA BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 N 25TH AVE STE 185
PHOENIX AZ
85021-2717
US

IV. Provider business mailing address

2020 W UNION HILLS DR UNIT 215
PHOENIX AZ
85027-5816
US

V. Phone/Fax

Practice location:
  • Phone: 602-686-5779
  • Fax:
Mailing address:
  • Phone: 602-686-5779
  • 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 State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JERICHO CHEBULTZ
Title or Position: CEO
Credential:
Phone: 602-686-5779