Provider Demographics
NPI:1649644634
Name:INTEGRATED LIFE COUNSELING CENTER, PLLC
Entity type:Organization
Organization Name:INTEGRATED LIFE COUNSELING CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMMUNICATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LEE KAYE
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:651-242-9608
Mailing Address - Street 1:8931 33RD STREET N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8900
Mailing Address - Country:US
Mailing Address - Phone:651-242-9608
Mailing Address - Fax:651-756-8138
Practice Address - Street 1:8931 33RD STREET N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8900
Practice Address - Country:US
Practice Address - Phone:651-242-9608
Practice Address - Fax:651-756-8138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-14
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00241101YP2500X
MN920106H00000X
MN2005106H00000X
MNLP3782103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1629138417Medicaid
MN1225262496Medicaid
MN1114091709Medicaid
MN1154562205Medicaid