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Organization
CANYON REPOSE LLC
Active
Organization
CANYON REPOSE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JERRY MARONEY (DIRECTOR)
(602) 326-1828
Entity
Organization
Contact information
Practice address
8102 N 23RD AVE STE B, PHOENIX, AZ 85021-4962
(602) 326-1828
Mailing address
205 E OSBORN RD # 101, PHOENIX, AZ 85012-2327
(602) 628-0601
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
NULL
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YM0800X
Mental Health Counselor
Primary
—
NULL
101YM0800X
Mental Health Counselor
Primary
—
—
171M00000X
Case Manager/Care Coordinator
—
NULL
171M00000X
Case Manager/Care Coordinator
—
—
207R00000X
Internal Medicine Physician
—
NULL
207R00000X
Internal Medicine Physician
—
—
207RA0401X
Addiction Medicine (Internal Medicine) Physician
—
NULL
207RA0401X
Addiction Medicine (Internal Medicine) Physician
—
—
363LP2300X
Primary Care Nurse Practitioner
—
NULL
363LP2300X
Primary Care Nurse Practitioner
—
—
Other
Enumeration date
08/19/2025
Last updated
09/12/2025
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