MEDICARE: LIFE CHANGING INITIATIVES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1285596718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CHANGING INITIATIVES

Provider Business Mailing Address
First Line	:	4539 N 22ND ST STE 5174
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4639
Country	:	US
Telephone Number	:	520-306-9770
Fax Number	:

Provider Business Practice Location Address
First Line	:	4539 N 22ND ST STE 5174
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4639
Country	:	US
Telephone Number	:	520-306-9770
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	ROBERTA HARRIS
Credential	:
Telephone Number	:	520-306-9770

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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Directions to “LIFE CHANGING INITIATIVES ” Practice Location

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