Provider Demographics
NPI:1649897414
Name:DESERT BOLT BEHAVIORAL LLC
Entity type:Organization
Organization Name:DESERT BOLT BEHAVIORAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VALERY
Authorized Official - Middle Name:A
Authorized Official - Last Name:NKENDONG
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:480-527-0042
Mailing Address - Street 1:42201 N 41ST DR STE 160
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3803
Mailing Address - Country:US
Mailing Address - Phone:850-527-0042
Mailing Address - Fax:480-296-0002
Practice Address - Street 1:42201 N 41ST DR STE 160
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3803
Practice Address - Country:US
Practice Address - Phone:850-527-0042
Practice Address - Fax:480-296-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-28
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ120200727001036Medicaid