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General NPI Number Information
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NPI Number | 1104595586
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Entity Type | Organization
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Legal Business Name | GOOD LIFE MENTAL HALTH SERVICES LLC
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Dates
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Enumeration Date | 09/09/2021
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Last Update Date | 09/09/2021
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Provider Practice Location Address
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Address Line | 13406 PINEVIEW CT
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City | DAYTON
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State | MN
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Zip | 55327-4500
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Country | US
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Telephone | 612-636-9268
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 722793
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City | SAN DIEGO
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State | CA
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Zip | 92172-2793
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Country | US
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Telephone | 612-636-9268
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Fax | 612-235-3392
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Authorized Official
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Title or Position | CLINICAL SOCIAL WORKER
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Name | DIMITRIY B ZELIKMAN
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Credential | LCSW
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Telephone | 612-636-9268
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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