Provider Demographics
NPI:1942708573
Name:LIFE ON PURPOSE COUNSELING & NEUROFEEDBACK INC
Entity type:Organization
Organization Name:LIFE ON PURPOSE COUNSELING & NEUROFEEDBACK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DANNIELLE
Authorized Official - Middle Name:MARIE FLADTEN
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:651-600-7876
Mailing Address - Street 1:312 COUNTY ROAD D E
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1275
Mailing Address - Country:US
Mailing Address - Phone:651-600-7876
Mailing Address - Fax:651-705-8181
Practice Address - Street 1:312 COUNTY ROAD D E
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1275
Practice Address - Country:US
Practice Address - Phone:651-600-7876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-29
Last Update Date:2018-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN184631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1942708573Medicaid