Provider Demographics
NPI:1033229281
Name:LIFESPAN BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:LIFESPAN BEHAVIORAL HEALTH, LLC
Other - Org Name:INDIVIDUAL AND FAMILY PSYCHOLOGICAL SERVICES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:COLBY
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:602-622-3021
Mailing Address - Street 1:1745 S ALMA SCHOOL RD
Mailing Address - Street 2:172
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3009
Mailing Address - Country:US
Mailing Address - Phone:602-324-4676
Mailing Address - Fax:480-209-1063
Practice Address - Street 1:1745 S ALMA SCHOOL RD
Practice Address - Street 2:172
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3009
Practice Address - Country:US
Practice Address - Phone:602-324-4676
Practice Address - Fax:480-209-1063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3676103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ944654Medicaid
AZ944654OtherMERCY CARE
AZ372456OtherMHN
AZ944654OtherEVERCARE
AZ372456OtherMHN
AZ944654OtherMERCY CARE