Healthcare Provider Details

I. General information

NPI: 1679112619
Provider Name (Legal Business Name): ENGAGING LIFE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2019
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 N 113TH AVE STE B9
YOUNGTOWN AZ
85363-1163
US

IV. Provider business mailing address

12600 N 113TH AVE STE B9
YOUNGTOWN AZ
85363-1163
US

V. Phone/Fax

Practice location:
  • Phone: 602-845-0767
  • Fax: 602-715-0647
Mailing address:
  • Phone: 602-845-0767
  • Fax: 602-715-0647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. PAMELA ROBINSON
Title or Position: EXECUTIVE MEDICAL DIRECTOR/COO
Credential: DNP, PSYD
Phone: 602-845-0767