Provider Demographics
NPI:1326304023
Name:LIFE ENHANCEMENT CENTER
Entity Type:Organization
Organization Name:LIFE ENHANCEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASS. CLINICAL MENTAL HEALTH COUNSEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:ACMHC
Authorized Official - Phone:801-796-0620
Mailing Address - Street 1:1835 N 1120 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1180
Mailing Address - Country:US
Mailing Address - Phone:801-623-4770
Mailing Address - Fax:801-623-4771
Practice Address - Street 1:1835 N 1120 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1180
Practice Address - Country:US
Practice Address - Phone:801-623-4770
Practice Address - Fax:801-623-4771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5828209-6009261QM0850X
UT5828209-6009261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health