Provider Demographics
NPI:1598077562
Name:LIFE CHANGE ASSOCIATES, PC
Entity Type:Organization
Organization Name:LIFE CHANGE ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERIC
Authorized Official - Middle Name:V
Authorized Official - Last Name:RAVSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-233-5433
Mailing Address - Street 1:1777 E CLARK ST
Mailing Address - Street 2:SUITE 330
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3357
Mailing Address - Country:US
Mailing Address - Phone:208-233-5433
Mailing Address - Fax:877-284-2783
Practice Address - Street 1:1777 E CLARK ST
Practice Address - Street 2:SUITE 330
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3357
Practice Address - Country:US
Practice Address - Phone:208-233-5433
Practice Address - Fax:877-284-2783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-07
Last Update Date:2013-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X, 2084P0800X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty