Provider Demographics
NPI:1689186587
Name:LIFE TRANSFORMATIONS
Entity Type:Organization
Organization Name:LIFE TRANSFORMATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADDICTION COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MATA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-640-8915
Mailing Address - Street 1:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56538-0703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 6TH ST N
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1503
Practice Address - Country:US
Practice Address - Phone:701-640-8915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty