Provider Demographics
NPI:1760892244
Name:INTENTIONAL SELF COUNSELING, COACHING, AND CONSULTATION
Entity Type:Organization
Organization Name:INTENTIONAL SELF COUNSELING, COACHING, AND CONSULTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE EBENHOCH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:763-228-4752
Mailing Address - Street 1:2547 DAHL AVE E
Mailing Address - Street 2:MAPLEWOOD
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-6500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1154 GRAND AVE STE 2
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2628
Practice Address - Country:US
Practice Address - Phone:763-228-4752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1939251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health