NPIMap

Organization Active NPI

Life Change Associates, PC

  • Psychiatry Physician
  • Pocatello, ID
National Provider Identifier
1598077562
Registry record updated Nov 23, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
LIFE CHANGE ASSOCIATES, PC
Practice address
1777 E Clark St
Suite 330
Pocatello, ID 83201-3357
Phone
(208) 233-5433
Fax
(877) 284-2783
NPI assigned
Jul 7, 2010
Last updated
Nov 23, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 23, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Deric V Ravsten, DONPI 1154431542
Title
Owner
Phone
(208) 233-5433

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 101YM0800X ID
Psychiatry PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 2084P0800X ID Primary
Physician AssistantGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363A00000X ID

Addresses

Primary practice location

1777 E Clark St
Suite 330
Pocatello, ID 83201-3357

Mailing address

1777 E Clark St
Suite 330
Pocatello, ID 83201-3357
Phone (208) 233-5433

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20131212001598 ID Part B Supplier - Clinic/Group Practice 8224265574 Receives reassigned benefits from 12 practitioners
Practice locations: Blackfoot, ID; Burley, ID; Idaho Falls, ID; Pocatello, ID

National Provider Directory

National Provider Directory

Locations

1404 Pomerelle Ave
Ste 150
Burley, ID 83318
Phone (208) 233-5433

1777 E Clark St
Ste 300
Pocatello, ID 83201
Phone (208) 233-5433

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1278460800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1385164800000",
    "number": "1598077562",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1777 E CLARK ST",
            "address_2": "SUITE 330",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832013357",
            "telephone_number": "208-233-5433",
            "fax_number": "877-284-2783"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1777 E CLARK ST",
            "address_2": "SUITE 330",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832013357",
            "telephone_number": "208-233-5433",
            "fax_number": "877-284-2783"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFE CHANGE ASSOCIATES, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-07-07",
        "last_updated": "2013-11-23",
        "status": "A",
        "authorized_official_last_name": "RAVSTEN",
        "authorized_official_first_name": "DERIC",
        "authorized_official_middle_name": "V",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-233-5433",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": "ID",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "ID",
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "ID",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pocatello, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 23, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.