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General NPI Number Information
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NPI Number | 1114368867
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Entity Type | Organization
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Legal Business Name | LIFE IDEALS, LLC
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Dates
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Enumeration Date | 07/10/2013
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Last Update Date | 07/10/2013
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Provider Practice Location Address
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Address Line | 178 LISBON ST 3RD FLOOR
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City | LEWISTON
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State | ME
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Zip | 04240-7234
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Country | US
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Telephone | 207-333-3507
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Fax |
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Provider Business Mailing Address
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Address Line | 178 LISBON ST 3RD FLOOR
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City | LEWISTON
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State | ME
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Zip | 04240-7234
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Country | US
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Telephone | 207-333-3507
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KAREN BURKE LANE
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Credential | LCSW
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Telephone | 207-333-3507
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LC8317
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LC10597
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License Number State | ME
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