Healthcare Provider Details

I. General information

NPI: 1932988763
Provider Name (Legal Business Name): BACK TO LIFE MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20860 N TATUM BLVD
PHOENIX AZ
85050-4274
US

IV. Provider business mailing address

20860 N TATUM BLVD
PHOENIX AZ
85050-4274
US

V. Phone/Fax

Practice location:
  • Phone: 503-833-3778
  • Fax:
Mailing address:
  • Phone: 503-833-3778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LOGAN ELI CARTON
Title or Position: MANAGER/OWNER
Credential: PMHNP
Phone: 480-353-7133