Healthcare Provider Details

I. General information

NPI: 1285823377
Provider Name (Legal Business Name): LIFELINE PROFESSIONAL COUNSELING SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 N. ALMA SCHOOL RD STE E
CHANDLER AZ
85224
US

IV. Provider business mailing address

335 N. ALMA SCHOOL RD STE E
CHANDLER AZ
85224
US

V. Phone/Fax

Practice location:
  • Phone: 480-641-1165
  • Fax: 480-641-9026
Mailing address:
  • Phone: 480-641-1165
  • Fax: 480-641-9026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberOTC6153
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ROXANNE DALTOS
Title or Position: PRES.
Credential: PHD
Phone: 480-641-1165