Basic Information
| Provider Information | |||||||||
| NPI: | 1154401156 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFEWELL BEHAVIORAL WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 E. EARLL DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028082800 | ||||||||
| FaxNumber: | 6028082799 | ||||||||
| Practice Location | |||||||||
| Address1: | 3222 N 37TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850186304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028082800 | ||||||||
| FaxNumber: | 6028082799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 12/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCKELVEY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6025995410 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | BH2406 | AZ | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 056970 | 05 | AZ | MEDICAID |