Healthcare Provider Details

I. General information

NPI: 1902594823
Provider Name (Legal Business Name): NOVA CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6049 E GRANT RD
TUCSON AZ
85712-2317
US

IV. Provider business mailing address

1717 W NORTHERN AVE STE 204D
PHOENIX AZ
85021-5471
US

V. Phone/Fax

Practice location:
  • Phone: 623-986-5609
  • Fax:
Mailing address:
  • Phone: 480-499-3571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SOHAIL DAULAT
Title or Position: ADMINISTRATOR
Credential:
Phone: 623-986-5609