Healthcare Provider Details

I. General information

NPI: 1992208623
Provider Name (Legal Business Name): CONSULT 4 CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 E RAY RD SUITE 23-266
PHOENIX AZ
85044-0620
US

IV. Provider business mailing address

4802 E RAY RD SUITE 23-266
PHOENIX AZ
85044
US

V. Phone/Fax

Practice location:
  • Phone: 602-620-5507
  • Fax: 602-491-2677
Mailing address:
  • Phone: 313-590-5253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLPC16755
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. LAJUANA E MITCHELL
Title or Position: LPC
Credential: MA
Phone: 313-590-5253