# CANYON REPOSE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376420596
- **Authorized official:** JERRY MARONEY (DIRECTOR)
- **Authorized official phone:** (602) 326-1828

## Contact information

- **Practice address:** 8102 N 23RD AVE STE B, PHOENIX, AZ 85021-4962
- **Practice address phone:** (602) 326-1828
- **Mailing address:** 205 E OSBORN RD \# 101, PHOENIX, AZ 85012-2327
- **Mailing address phone:** (602) 628-0601

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YA0400X | Addiction (Substance Use Disorder) Counselor | — | NULL | — |
| 101YA0400X | Addiction (Substance Use Disorder) Counselor | — | — | — |
| 101YM0800X | Mental Health Counselor | — | NULL | Yes |
| 101YM0800X | Mental Health Counselor | — | — | Yes |
| 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