Provider Demographics
NPI:1417283946
Name:CENTERLIFE COUNSELING, LLC
Entity Type:Organization
Organization Name:CENTERLIFE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LUNDHOLM-EADES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-288-0332
Mailing Address - Street 1:7039 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55038-9737
Mailing Address - Country:US
Mailing Address - Phone:651-288-0332
Mailing Address - Fax:
Practice Address - Street 1:7039 20TH AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MN
Practice Address - Zip Code:55038-9737
Practice Address - Country:US
Practice Address - Phone:651-288-0332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-18
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 103T00000X, 103TC0700X, 103TC2200X, 103TF0000X, 1041C0700X, 106H00000X, 261QM0801X
MN942106H00000X, 106H00000X
MN3041041C0700X
MNCC00482101YM0800X
MN2919106H00000X
MN1825106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty