Healthcare Provider Details

I. General information

NPI: 1689307480
Provider Name (Legal Business Name): OPEN GATE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 N 19TH AVE STE 204
PHOENIX AZ
85021-7981
US

IV. Provider business mailing address

7550 N 19TH AVE STE 204
PHOENIX AZ
85021-7981
US

V. Phone/Fax

Practice location:
  • Phone: 602-675-2507
  • Fax:
Mailing address:
  • Phone: 602-675-2507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation 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: EDWINA JOHNSON
Title or Position: OWNER
Credential:
Phone: 914-338-6145