Provider Demographics
NPI:1467639302
Name:CIRCLE OF LIFE COUNSELING, PLLC
Entity Type:Organization
Organization Name:CIRCLE OF LIFE COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATUTORY AGENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:602-420-3406
Mailing Address - Street 1:1474 N COOPER RD
Mailing Address - Street 2:SUITE 105-443
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-1237
Mailing Address - Country:US
Mailing Address - Phone:602-410-3406
Mailing Address - Fax:480-636-8440
Practice Address - Street 1:4121 E VALLEY AUTO DR
Practice Address - Street 2:SUITE 122
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4631
Practice Address - Country:US
Practice Address - Phone:602-410-3406
Practice Address - Fax:480-636-8440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC12028101YM0800X
AZLCSW103801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty