Organization
A NEW LEAF
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GRACIA DANIS (CREDENTIALING SPECIALIST)
(520) 591-5394
Entity
Organization
Contact information
Practice address
8581 N 61ST AVE BLDG A, GLENDALE, AZ 85302-5493
(623) 934-1991
(623) 878-9335
Mailing address
868 E UNIVERSITY DR, MESA, AZ 85203-8033
(480) 969-4024
(480) 969-0039
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
261QP2300X
Primary Care Clinic/Center
OTC6465
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
433108
—
AZ
01
—
OTC6465
STATE LICENSE
AZ
Enumeration date
08/06/2013
Last updated
07/31/2024
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