Provider Demographics
NPI:1689756215
Name:LIFEWELL BEHAVIORAL WELLNESS
Entity Type:Organization
Organization Name:LIFEWELL BEHAVIORAL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCKELVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-553-7300
Mailing Address - Street 1:2715 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1100
Mailing Address - Country:US
Mailing Address - Phone:602-553-7300
Mailing Address - Fax:602-553-7303
Practice Address - Street 1:650 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5032
Practice Address - Country:US
Practice Address - Phone:602-553-7300
Practice Address - Fax:602-553-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH - 2935251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health