Healthcare Provider Details

I. General information

NPI: 1104595586
Provider Name (Legal Business Name): GOOD LIFE MENTAL HALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13406 PINEVIEW CT
DAYTON MN
55327-4500
US

IV. Provider business mailing address

PO BOX 722793
SAN DIEGO CA
92172-2793
US

V. Phone/Fax

Practice location:
  • Phone: 612-636-9268
  • Fax:
Mailing address:
  • Phone: 612-636-9268
  • Fax: 612-235-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIMITRIY B ZELIKMAN
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 612-636-9268