Provider Demographics
NPI:1033821632
Name:LIFE INTERRUPTED COUNSELING SERVICES
Entity Type:Organization
Organization Name:LIFE INTERRUPTED COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHEDDA
Authorized Official - Suffix:
Authorized Official - Credentials:MM, MA, LMFT
Authorized Official - Phone:651-338-8643
Mailing Address - Street 1:1500 MCANDREWS RD W STE 215
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4445
Mailing Address - Country:US
Mailing Address - Phone:651-338-8643
Mailing Address - Fax:
Practice Address - Street 1:1500 MCANDREWS RD W STE 215
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4445
Practice Address - Country:US
Practice Address - Phone:952-222-3002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1861931966OtherINDIVIDUAL NPI
MN1861931966Medicaid