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General NPI Number Information
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NPI Number | 1619107232
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Entity Type | Organization
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Legal Business Name | LIVING WITH DIGNITY CENTER
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Dates
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Enumeration Date | 07/16/2009
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Last Update Date | 07/16/2009
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Provider Practice Location Address
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Address Line | 11260 QUINN ST NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-3631
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Country | US
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Telephone | 612-747-0414
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Fax | 763-205-3080
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Provider Business Mailing Address
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Address Line | 11260 QUINN ST NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-3631
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Country | US
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Telephone | 612-747-0414
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Fax | 763-205-3080
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. ALICIA V FAHR
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Credential | PHD
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Telephone | 763-205-3080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LPC00616
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1051192-1-ADC
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License Number State | MN
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