Healthcare Provider Details

I. General information

NPI: 1184402505
Provider Name (Legal Business Name): LIVE LIFE BALANCED HEALING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2546 JOHNSON ST NE
MINNEAPOLIS MN
55418-3941
US

IV. Provider business mailing address

2546 JOHNSON ST NE
MINNEAPOLIS MN
55418-3941
US

V. Phone/Fax

Practice location:
  • Phone: 612-444-1655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. SHIREEN GHANATABADI
Title or Position: OWNER/THERAPIST
Credential: MA, LPCC, SEP
Phone: 612-444-1655