=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104089648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE MANAGEMENT RESOURCES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2008
-----------------------------------------------------
Last Update Date | 07/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 12TH AVE NE
-----------------------------------------------------
City | DEVILS LAKE
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58301-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-665-5433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 12TH AVE NE
-----------------------------------------------------
City | DEVILS LAKE
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58301-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-665-5433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARYJANE BLANCHFIELD
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 701-665-5433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 603
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------