Healthcare Provider Details

I. General information

NPI: 1548017759
Provider Name (Legal Business Name): SPIRITUAL HEALING LIFE COACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 7TH ST E
SAINT PAUL MN
55101-2349
US

IV. Provider business mailing address

1194 ALBEMARLE ST
SAINT PAUL MN
55117-4418
US

V. Phone/Fax

Practice location:
  • Phone: 612-236-3204
  • Fax:
Mailing address:
  • Phone: 612-236-3204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: EBONY STEVENSON
Title or Position: CEO
Credential:
Phone: 612-236-3204