Basic Information
| Provider Information | |||||||||
| NPI: | 1609251057 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFEWELL BEHAVIORAL WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 E EARLL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028082800 | ||||||||
| FaxNumber: | 6028082799 | ||||||||
| Practice Location | |||||||||
| Address1: | 3540 E BASELINE RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850429630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028082800 | ||||||||
| FaxNumber: | 6028082799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2015 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHT | ||||||||
| AuthorizedOfficialFirstName: | DORIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | ECECUTIVE VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6025995420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | OTC7810 | AZ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 037445 | 05 | AZ | MEDICAID |