Provider Demographics
NPI:1285823377
Name:LIFELINE PROFESSIONAL COUNSELING SERVICES, INC
Entity Type:Organization
Organization Name:LIFELINE PROFESSIONAL COUNSELING SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:480-641-1165
Mailing Address - Street 1:335 N. ALMA SCHOOL RD
Mailing Address - Street 2:STE E
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224
Mailing Address - Country:US
Mailing Address - Phone:480-641-1165
Mailing Address - Fax:480-641-9026
Practice Address - Street 1:335 N. ALMA SCHOOL RD
Practice Address - Street 2:STE E
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-641-1165
Practice Address - Fax:480-641-9026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
AZOTC6153261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty