Provider Demographics
NPI:1609420959
Name:DENOVA COLLABORATIVE HEALTH, LLC
Entity Type:Organization
Organization Name:DENOVA COLLABORATIVE HEALTH, LLC
Other - Org Name:DENOVA COLLABORATIVE HEALTH, LLC
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 550
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2635
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:
Practice Address - Street 1:750 E THUNDERBIRD RD # 1-3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5306
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:602-218-6383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-25
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty