Provider Demographics
NPI:1720580038
Name:LIFELINE PROFESSIONAL COUNSELING SERVICES, INC
Entity Type:Organization
Organization Name:LIFELINE PROFESSIONAL COUNSELING SERVICES, INC
Other - Org Name:LIFELINE WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DELORENZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-641-1165
Mailing Address - Street 1:17235 N 75TH AVE STE F100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-0871
Mailing Address - Country:US
Mailing Address - Phone:480-641-1165
Mailing Address - Fax:
Practice Address - Street 1:17235 N 75TH AVE SUITE F-100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:480-641-1165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4970261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)