Provider Demographics
NPI:1972868057
Name:LIFE RIPPLES LLC
Entity Type:Organization
Organization Name:LIFE RIPPLES LLC
Other - Org Name:LIFE RIPPLES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:612-567-0267
Mailing Address - Street 1:1123 GRAND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2629
Mailing Address - Country:US
Mailing Address - Phone:612-567-0267
Mailing Address - Fax:
Practice Address - Street 1:1123 GRAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-2629
Practice Address - Country:US
Practice Address - Phone:612-567-0267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5037251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1861633349Medicaid