Provider Demographics
NPI:1518150317
Name:WELLIFE COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:WELLIFE COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:G
Authorized Official - Last Name:VACCARO
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW
Authorized Official - Phone:928-636-7890
Mailing Address - Street 1:PO BOX 2863
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-2703
Mailing Address - Country:US
Mailing Address - Phone:928-636-7890
Mailing Address - Fax:
Practice Address - Street 1:1968 US HIGHWAY 89 SOUTH
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323
Practice Address - Country:US
Practice Address - Phone:928-636-7890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW10904251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherEIN
AZZ79424Medicare PIN