Provider Demographics
NPI:1801016878
Name:PROFESSIONAL PSYCHOLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHOLOGY ASSOCIATES, PC
Other - Org Name:CENTER FOR LIFESTYLE CHANGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:D
Authorized Official - Last Name:LETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:602-852-0911
Mailing Address - Street 1:4222 E CAMELBACK ROAD
Mailing Address - Street 2:SUITE H230
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2787
Mailing Address - Country:US
Mailing Address - Phone:602-852-0911
Mailing Address - Fax:602-852-0632
Practice Address - Street 1:4222 E CAMELBACK RD
Practice Address - Street 2:SUITE H230
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2745
Practice Address - Country:US
Practice Address - Phone:602-852-0911
Practice Address - Fax:602-852-0632
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL PSYCHLOGY ASSOCIATES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-01
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH934261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder