Healthcare Provider Details

I. General information

NPI: 1013601426
Provider Name (Legal Business Name): NEW LIFE OF LOVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 N BLACK CANYON HWY UNIT C1
PHOENIX AZ
85009-2910
US

IV. Provider business mailing address

1622 N BLACK CANYON HWY UNIT C1
PHOENIX AZ
85009-2910
US

V. Phone/Fax

Practice location:
  • Phone: 214-907-0589
  • Fax:
Mailing address:
  • Phone: 214-907-0589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MISS KELLI CHILDERS
Title or Position: CEO
Credential:
Phone: 214-907-0589