| Life Change Associates, Pc | |
|
1777 E Clark St Suite 330 Pocatello ID 83201-3357 | |
| (208) 233-5433 | |
| (877) 284-2783 |
| Full Name | Life Change Associates, Pc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 1777 E Clark St, Pocatello, Idaho |
| Authorized Official Name and Position | Deric V Ravsten (OWNER) |
| Authorized Official Contact | 2082335433 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Life Change Associates, Pc 1777 E Clark St Suite 330 Pocatello ID 83201-3357 Ph: (208) 233-5433 | Life Change Associates, Pc 1777 E Clark St Suite 330 Pocatello ID 83201-3357 Ph: (208) 233-5433 |
| NPI Number | 1598077562 |
|---|---|
| Provider Enumeration Date | 07/07/2010 |
| Last Update Date | 11/23/2013 |
| Medicare PECOS PAC ID | 8224265574 |
|---|---|
| Medicare Enrollment ID | O20131212001598 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1598077562 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (Idaho) | Secondary |
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (Idaho) | Primary |
| 363A00000X | Physician Assistant | (Idaho) | Secondary |
| Provider Name | Deric V Ravsten |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1154431542 PECOS PAC ID: 4688636129 Enrollment ID: I20041027001257 |
| Provider Name | Karen D Donaldson |
|---|---|
| Provider Type | Practitioner - Registered Dietitian Or Nutrition Professional |
| Provider Identifiers | NPI Number: 1699705087 PECOS PAC ID: 9931224631 Enrollment ID: I20100918000054 |
| Provider Name | Stephanie A Clark |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1912288572 PECOS PAC ID: 9335311406 Enrollment ID: I20111013000668 |
| Provider Name | Angela K. Kelly |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1497015143 PECOS PAC ID: 0042591208 Enrollment ID: I20161229001576 |
| Provider Name | Tiffany Ann Bascom |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1487701058 PECOS PAC ID: 8527419308 Enrollment ID: I20240105000876 |
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