Provider Demographics
NPI:1467182774
Name:IDEAL SELF LLC
Entity Type:Organization
Organization Name:IDEAL SELF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, PMHNP
Authorized Official - Phone:623-303-6777
Mailing Address - Street 1:12620 N CAVE CREEK RD STE 10A
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-6528
Mailing Address - Country:US
Mailing Address - Phone:623-303-6777
Mailing Address - Fax:
Practice Address - Street 1:12620 N CAVE CREEK RD STE 10A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-6528
Practice Address - Country:US
Practice Address - Phone:623-303-6777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-10
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty