MEDICARE: NEW LEAF RECOVERY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1477422400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW LEAF RECOVERY CENTER

Provider Business Mailing Address
First Line	:	4444 W NORTHERN AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85301-1683
Country	:	US
Telephone Number	:	818-770-4914
Fax Number	:

Provider Business Practice Location Address
First Line	:	4444 W NORTHERN AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85301-1683
Country	:	US
Telephone Number	:	818-770-4914
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	IAN MAZIMPAKA
Credential	:
Telephone Number	:	602-919-3389

Provider Enumeration Date	:	10/29/2025
Last Update Date	:	04/08/2026

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Directions to “NEW LEAF RECOVERY CENTER ” Practice Location

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