Healthcare Provider Details

I. General information

NPI: 1336721364
Provider Name (Legal Business Name): MANES FOR CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1884 MAHOGANY ST
MORA MN
55051-7111
US

IV. Provider business mailing address

1884 MAHOGANY ST
MORA MN
55051-7111
US

V. Phone/Fax

Practice location:
  • Phone: 320-339-9963
  • Fax: 320-348-7257
Mailing address:
  • Phone: 320-339-9963
  • Fax: 320-348-7257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JAMIE ROSE BANKERS
Title or Position: OWNER / CLINICAL THERAPIST
Credential: MA, LADC, LPCC
Phone: 320-339-9963