Healthcare Provider Details

I. General information

NPI: 1841683943
Provider Name (Legal Business Name): UPLIFTING LIVES CLINIC OF ARIZONA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 N 99TH AVE APT. 1097
GLENDALE AZ
85305-3001
US

IV. Provider business mailing address

5150 N 99TH AVE APT. 1097
GLENDALE AZ
85305-3001
US

V. Phone/Fax

Practice location:
  • Phone: 602-670-6077
  • Fax:
Mailing address:
  • Phone: 602-670-6077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MS. SHANNON CAROLYN PHILLIPS
Title or Position: OWNER/CLINICAL DIRECTOR
Credential:
Phone: 602-670-6077