Provider Demographics
NPI:1922624220
Name:FIT4 AN EMPOWERED LIFE LLC
Entity Type:Organization
Organization Name:FIT4 AN EMPOWERED LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAJUANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:313-590-5253
Mailing Address - Street 1:4802 E RAY RD SUITE 23-266
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85076-1492
Mailing Address - Country:US
Mailing Address - Phone:313-590-5253
Mailing Address - Fax:602-491-2677
Practice Address - Street 1:4802 E RAY RD STE 23-266
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6405
Practice Address - Country:US
Practice Address - Phone:313-590-5253
Practice Address - Fax:602-491-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-23
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
Yes251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ277387Medicaid
AZ23098837OtherENTITY ID