Basic Information
| Provider Information | |||||||||
| NPI: | 1730474693 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 6028082755 | ||||||||
| Practice Location | |||||||||
| Address1: | 10844 N 23RD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850294947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028082800 | ||||||||
| FaxNumber: | 6022622111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHT | ||||||||
| AuthorizedOfficialFirstName: | DORIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT /CEO | ||||||||
| AuthorizedOfficialTelephone: | 6025995420 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | OTC6575 | AZ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 617183 | 05 | AZ | MEDICAID |