Healthcare Provider Details

I. General information

NPI: 1588920615
Provider Name (Legal Business Name): LIFEPLACE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 S MILWAUKEE AVE SUITE 307
LIBERTYVILLE IL
60048-3764
US

IV. Provider business mailing address

1580 S MILWAUKEE AVE SUITE 307
LIBERTYVILLE IL
60048-3764
US

V. Phone/Fax

Practice location:
  • Phone: 847-557-0645
  • Fax: 847-557-9809
Mailing address:
  • Phone: 847-557-0645
  • Fax: 847-557-9809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180003417
License Number StateIL

VIII. Authorized Official

Name: MR. DREW MICHAEL MJOEN
Title or Position: PRESIDENT
Credential: M.A., LCPC
Phone: 847-557-0645