Provider Demographics
NPI:1790160141
Name:LIFEWELL BEHAVIORAL WELLNESS
Entity Type:Organization
Organization Name:LIFEWELL BEHAVIORAL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-599-5420
Mailing Address - Street 1:202 E EARLL DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2647
Mailing Address - Country:US
Mailing Address - Phone:602-808-2800
Mailing Address - Fax:602-808-2799
Practice Address - Street 1:4451 E OAK ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-2410
Practice Address - Country:US
Practice Address - Phone:602-808-2800
Practice Address - Fax:602-808-2799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0TC7467251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ037418Medicaid
AZZ102186Medicare UPIN