Provider Demographics
NPI:1326757865
Name:PHAM, JULIE LIFESTYLE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:LIFESTYLE
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 S ALMA SCHOOL RD STE 4
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-1091
Mailing Address - Country:US
Mailing Address - Phone:480-699-9299
Mailing Address - Fax:
Practice Address - Street 1:810 S ALMA SCHOOL RD STE 4
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-1091
Practice Address - Country:US
Practice Address - Phone:480-699-9299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCSLG12053101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ883852528Medicaid