Provider Demographics
NPI:1124549043
Name:DENOVA COLLABORATIVE HEALTH, LLC
Entity Type:Organization
Organization Name:DENOVA COLLABORATIVE HEALTH, LLC
Other - Org Name:DENOVA COLLABORATIVE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-230-7373
Mailing Address - Street 1:3101 N CENTRAL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2639
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:602-682-7455
Practice Address - Street 1:2204 S DOBSON RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6457
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YM0800X, 207Q00000X, 2084P0800X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid