=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265974943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZ FAMILY LIFE COUNSELING COACHING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2016
-----------------------------------------------------
Last Update Date | 11/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34406 N 27TH DR BUILDING 6, SUITE 140
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85085-6082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-535-5028
-----------------------------------------------------
Fax | 480-535-5028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34406 N 27TH DR BUILDING 6, SUITE 140
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85085-6082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-535-5028
-----------------------------------------------------
Fax | 480-535-5028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MRS. CRISTIN MARIE MULLEN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 602-316-9899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-15944
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------