| Desert Bolt Behavioral LLC | |
|
42201 N 41st Dr Ste 160 Anthem AZ 85086-3803 | |
| (850) 527-0042 | |
| (480) 296-0002 |
| Full Name | Desert Bolt Behavioral LLC |
|---|---|
| Speciality | Clinic/Center |
| Location | 42201 N 41st Dr Ste 160, Anthem, Arizona |
| Authorized Official Name and Position | Valery a Nkendong (CEO) |
| Authorized Official Contact | 4805270042 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Desert Bolt Behavioral LLC 42201 N 41st Dr Ste 160 Anthem AZ 85086-3803 Ph: (850) 527-0042 | Desert Bolt Behavioral LLC 42201 N 41st Dr Ste 160 Anthem AZ 85086-3803 Ph: (850) 527-0042 |
| NPI Number | 1649897414 |
|---|---|
| Provider Enumeration Date | 06/28/2020 |
| Last Update Date | 07/05/2021 |
| Certification Date | 07/05/2021 |
| Medicare PECOS PAC ID | 0446662241 |
|---|---|
| Medicare Enrollment ID | O20201221001409 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1649897414 | NPI | - | NPPES |
| 120200727001036 | Medicaid | AZ |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | () | Primary |
| 363LP0808X | Nurse Practitioner - Psychiatric/mental Health | () | Secondary |
| Provider Name | Ray L Hamilton |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1184198475 PECOS PAC ID: 4880928118 Enrollment ID: I20190620001401 |
| Provider Name | Valery Ayafor Nkendong |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1336763218 PECOS PAC ID: 8022432871 Enrollment ID: I20201221001454 |
| Provider Name | Hannah Parrish |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1053027250 PECOS PAC ID: 0840665998 Enrollment ID: I20230404000548 |
| Provider Name | Michael Bass |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1235829201 PECOS PAC ID: 8123486495 Enrollment ID: I20230619000175 |
| Provider Name | Jennifer Whelan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1669236584 PECOS PAC ID: 5799284725 Enrollment ID: I20250818001353 |
| Provider Name | Grace Chidinma Ezenwaka |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1023906997 PECOS PAC ID: 4082101852 Enrollment ID: I20251015000839 |
| Provider Name | Nidal Abukhalil |
|---|---|
| Provider Type | Practitioner - Physician Assistant |
| Provider Identifiers | NPI Number: 1104667757 PECOS PAC ID: 0941777601 Enrollment ID: I20260430000617 |
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