Provider Demographics
NPI:1811625734
Name:LIVE WELL COMMUNITY SERVICES
Entity type:Organization
Organization Name:LIVE WELL COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NOELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUVERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-206-9323
Mailing Address - Street 1:4214 N 45TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4309
Mailing Address - Country:US
Mailing Address - Phone:480-206-9323
Mailing Address - Fax:
Practice Address - Street 1:2901 E CAMELBACK RD STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4420
Practice Address - Country:US
Practice Address - Phone:480-206-9323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health