Provider Demographics
NPI:1497509509
Name:LIV WELL BEHAVIORAL
Entity type:Organization
Organization Name:LIV WELL BEHAVIORAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DESIRAE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-326-0688
Mailing Address - Street 1:2150 S COUNTRY CLUB DR STE 27
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2150 S COUNTRY CLUB DR STE 27
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6860
Practice Address - Country:US
Practice Address - Phone:602-856-6535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIV WELL BEHAVIORAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-15
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH9812OtherADHS