Healthcare Provider Details

I. General information

NPI: 1386483592
Provider Name (Legal Business Name): LIFETREE COUNSELING CENTER OF ARIZONA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11225 N 28TH DR STE A210
PHOENIX AZ
85029-5646
US

IV. Provider business mailing address

11225 N 28TH DR STE A210
PHOENIX AZ
85029-5646
US

V. Phone/Fax

Practice location:
  • Phone: 623-313-4739
  • Fax:
Mailing address:
  • Phone: 623-313-4739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DONIEL EUGENE GUDEMAN
Title or Position: CHIEF ADMINISTRATOR
Credential:
Phone: 480-462-8561