Healthcare Provider Details

I. General information

NPI: 1669901393
Provider Name (Legal Business Name): DEVELOPMENTAL IMPACT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 8TH AVE N
SAINT CLOUD MN
56303-3420
US

IV. Provider business mailing address

720 8TH AVE N
SAINT CLOUD MN
56303-3420
US

V. Phone/Fax

Practice location:
  • Phone: 320-420-2234
  • Fax: 320-251-0217
Mailing address:
  • Phone: 320-420-2234
  • Fax: 320-251-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2474
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2474
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2474
License Number StateMN

VIII. Authorized Official

Name: THERESA SCHREIFELS
Title or Position: CEO
Credential: LMFT
Phone: 320-420-2234