Provider Demographics
NPI:1316693419
Name:DESERT CLOVER PSYCHIATRY, LLC
Entity type:Organization
Organization Name:DESERT CLOVER PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KODYSZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-492-2121
Mailing Address - Street 1:2601 N 3RD ST STE 205
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1145
Mailing Address - Country:US
Mailing Address - Phone:602-492-2121
Mailing Address - Fax:
Practice Address - Street 1:2601 N 3RD ST STE 205
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1145
Practice Address - Country:US
Practice Address - Phone:602-492-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-28
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty