Provider Demographics
NPI:1982191284
Name:LIFEWELL BEHAVIORAL WELLNESS
Entity Type:Organization
Organization Name:LIFEWELL BEHAVIORAL WELLNESS
Other - Org Name:LIFEWELL BEHAVIORAL WELLNESS - ROYAL PALMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
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 DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2647
Mailing Address - Country:US
Mailing Address - Phone:602-599-5434
Mailing Address - Fax:602-599-5734
Practice Address - Street 1:10844 N 23RD AVE STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4947
Practice Address - Country:US
Practice Address - Phone:602-353-2340
Practice Address - Fax:602-353-2400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-23
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ444173Medicaid