=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609091008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE ROADS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 10/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1068 LAKE ST S SUITE 109
-----------------------------------------------------
City | FOREST LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55025-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-230-0492
-----------------------------------------------------
Fax | 651-982-6035
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1068 LAKE ST S SUITE 109
-----------------------------------------------------
City | FOREST LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55025-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-230-0492
-----------------------------------------------------
Fax | 651-982-6035
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHARON ROSE FRIES
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 651-230-0492
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 0938
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------