Healthcare Provider Details

I. General information

NPI: 1992538052
Provider Name (Legal Business Name): DIVINE LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 FREEPORT AVE NW
ELK RIVER MN
55330-4611
US

IV. Provider business mailing address

506 FREEPORT AVE NW
ELK RIVER MN
55330-4611
US

V. Phone/Fax

Practice location:
  • Phone: 763-200-4006
  • Fax:
Mailing address:
  • Phone: 763-200-4006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JOHN CARL TORKELSON
Title or Position: CEO
Credential: LMFT
Phone: 763-200-4006