MEDICARE: ONE LIFE CONSULTING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	171400000X	Health & Wellness Coach
2	172A00000X	Driver
3	175T00000X	Peer Specialist
4	225800000X	Recreation Therapist
5	374K00000X	Religious Nonmedical Practitioner
6	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1174395289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE LIFE CONSULTING

Provider Business Mailing Address
First Line	:	1453 N DYSART RD # 322
Second Line	:
City	:	AVONDALE
State	:	AZ
Zip	:	85323-1539
Country	:	US
Telephone Number	:	310-779-8804
Fax Number	:

Provider Business Practice Location Address
First Line	:	6107 E ENCANTO ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85205-5956
Country	:	US
Telephone Number	:	310-779-8804
Fax Number	:

Authorized Official
Title or Position	:	BEHAVIORAL HEALTH CONSULTANT
Name	:	MR. WALLACE CLYDE ANDREWS III
Credential	:	MA/THERAPIST
Telephone Number	:	480-925-1393

Provider Enumeration Date	:	10/23/2023
Last Update Date	:	10/23/2023

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Directions to “ONE LIFE CONSULTING ” Practice Location

Language	Start Address	Practice Location

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