=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144577099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE ENHANCEMENT TECHNOLOGIES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2012
-----------------------------------------------------
Last Update Date | 08/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1414 N NEVADA AVE
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80907-7431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-531-6078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 62595
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80962-2595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-531-6078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MIRIAM BLUM
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 719-531-6078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1167
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------