Healthcare Provider Details

I. General information

NPI: 1174395289
Provider Name (Legal Business Name): ONE LIFE CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6107 E ENCANTO ST
MESA AZ
85205-5956
US

IV. Provider business mailing address

1453 N DYSART RD # 322
AVONDALE AZ
85323-1539
US

V. Phone/Fax

Practice location:
  • Phone: 310-779-8804
  • Fax:
Mailing address:
  • Phone: 310-779-8804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. WALLACE CLYDE ANDREWS III
Title or Position: BEHAVIORAL HEALTH CONSULTANT
Credential: MA/THERAPIST
Phone: 480-925-1393