Healthcare Provider Details

I. General information

NPI: 1033821632
Provider Name (Legal Business Name): LIFE INTERRUPTED COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MCANDREWS RD W STE 215
BURNSVILLE MN
55337-4445
US

IV. Provider business mailing address

1500 MCANDREWS RD W STE 215
BURNSVILLE MN
55337-4445
US

V. Phone/Fax

Practice location:
  • Phone: 952-222-3002
  • Fax:
Mailing address:
  • Phone: 651-338-8643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY L CHEDDA
Title or Position: CEO/SOLE PROPRIETOR
Credential: MM, MA, LMFT
Phone: 651-338-8643