Provider Demographics
NPI:1336385970
Name:THERAPEUTIC LIFE CHANGES, LLC
Entity Type:Organization
Organization Name:THERAPEUTIC LIFE CHANGES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:701-483-5259
Mailing Address - Street 1:634 9TH AVE W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4745
Mailing Address - Country:US
Mailing Address - Phone:701-483-5259
Mailing Address - Fax:701-483-5259
Practice Address - Street 1:634 9TH AVE W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4745
Practice Address - Country:US
Practice Address - Phone:701-483-5259
Practice Address - Fax:701-483-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-04
Last Update Date:2009-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND30001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19242Medicaid