Healthcare Provider Details

I. General information

NPI: 1225045362
Provider Name (Legal Business Name): LIFETRACK RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 UNIVERSITY AVE W
SAINT PAUL MN
55104-4804
US

IV. Provider business mailing address

709 UNIVERSITY AVE W
SAINT PAUL MN
55104-4804
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-8471
  • Fax: 651-265-2318
Mailing address:
  • Phone: 651-227-8471
  • Fax: 651-265-2318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TRIXIE ANN GOLBERG
Title or Position: PRESIDENT
Credential:
Phone: 651-227-8471