Provider Demographics
NPI:1790409639
Name:LIFESPLACE COUNSELING, CONSULTING AND COACHING
Entity Type:Organization
Organization Name:LIFESPLACE COUNSELING, CONSULTING AND COACHING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPCC
Authorized Official - Phone:763-203-5550
Mailing Address - Street 1:29607 139TH ST NW
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-3688
Mailing Address - Country:US
Mailing Address - Phone:763-203-5550
Mailing Address - Fax:
Practice Address - Street 1:450 JEFFERSON BLVD STE 4
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-1902
Practice Address - Country:US
Practice Address - Phone:763-631-6325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty