Provider Demographics
NPI:1417050337
Name:LIFEWELL BEHAVIORAL WELLNESS
Entity Type:Organization
Organization Name:LIFEWELL BEHAVIORAL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCKELVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-599-5410
Mailing Address - Street 1:202 E EARLL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2634
Mailing Address - Country:US
Mailing Address - Phone:602-808-2800
Mailing Address - Fax:602-808-2799
Practice Address - Street 1:202 E EARLL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2634
Practice Address - Country:US
Practice Address - Phone:602-808-2800
Practice Address - Fax:602-808-2799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
AZBH3885251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ102186OtherMEDICARE PTAN