Healthcare Provider Details

I. General information

NPI: 1447302914
Provider Name (Legal Business Name): TRACK HOUSE LIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 N 7TH AVE STE 307
PHOENIX AZ
85013
US

IV. Provider business mailing address

4205 N 7TH AVE STE 307
PHOENIX AZ
85013-3080
US

V. Phone/Fax

Practice location:
  • Phone: 602-522-2595
  • Fax: 602-258-4996
Mailing address:
  • Phone: 602-522-2595
  • Fax: 602-258-4996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberCLSG7622
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELA ROBERSON
Title or Position: PRESIDENT
Credential: LCSW
Phone: 602-522-2595