Provider Demographics
NPI:1871915827
Name:DENOVA COLLABORATIVE HEALTH, LLC
Entity type:Organization
Organization Name:DENOVA COLLABORATIVE HEALTH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:602-682-7455
Practice Address - Street 1:3033 N CENTRAL AVE
Practice Address - Street 2:700
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2809
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:602-682-7455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC8131101YP2500X, 208000000X, 2084P0800X, 208D00000X
AZOTC5758261QM1300X
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ170664Medicaid
Z74487Medicare UPIN