Provider Demographics
NPI:1821003419
Name:PROFESSIONAL PSYCHOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHOLOGY ASSOCIATES PC
Other - Org Name:CENTER FOR LIFESTYLE CHANGE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
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 RD
Mailing Address - Street 2:SUITE H230
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2745
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH934103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty