Healthcare Provider Details

I. General information

NPI: 1285596718
Provider Name (Legal Business Name): LIFE CHANGING INITIATIVES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 N 22ND ST STE 5174
PHOENIX AZ
85016-4639
US

IV. Provider business mailing address

4539 N 22ND ST STE 5174
PHOENIX AZ
85016-4639
US

V. Phone/Fax

Practice location:
  • Phone: 520-306-9770
  • Fax:
Mailing address:
  • Phone: 520-306-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ROBERTA HARRIS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 520-306-9770