Provider Demographics
NPI:1659939536
Name:LIFE CHANGES MENTAL HEALTH SERVICES PLLC
Entity Type:Organization
Organization Name:LIFE CHANGES MENTAL HEALTH SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:VON BARGEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-791-6183
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:CRAIGMONT
Mailing Address - State:ID
Mailing Address - Zip Code:83523-0472
Mailing Address - Country:US
Mailing Address - Phone:208-791-6183
Mailing Address - Fax:949-404-8139
Practice Address - Street 1:816 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1870
Practice Address - Country:US
Practice Address - Phone:208-791-6183
Practice Address - Fax:949-404-8139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty