Healthcare Provider Details

I. General information

NPI: 1255547444
Provider Name (Legal Business Name): LIFEWELL BEHAVIORAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W. HIGHLAND AVENUE
PHOENIX AZ
85013-4707
US

IV. Provider business mailing address

202 E. EARLL DRIVE SUITE 200
PHOENIX AZ
85012-2647
US

V. Phone/Fax

Practice location:
  • Phone: 602-808-2800
  • Fax: 602-808-2799
Mailing address:
  • Phone: 602-808-2800
  • Fax: 602-808-2799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberBH2881
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH4220
License Number StateAZ

VIII. Authorized Official

Name: MR. THOMAS K MCKELVEY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 602-599-5410