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General NPI Number Information
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NPI Number | 1669838710
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Entity Type | Organization
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Legal Business Name | LIFE UNTANGLED, LLC
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Dates
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Enumeration Date | 01/05/2016
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Last Update Date | 01/05/2016
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Provider Practice Location Address
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Address Line | 330 W MAIN ST STE B
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City | STERLING
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State | CO
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Zip | 80751-3177
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Country | US
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Telephone | 970-520-0738
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Fax |
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Provider Business Mailing Address
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Address Line | 330 W MAIN ST STE B
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City | STERLING
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State | CO
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Zip | 80751-3177
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Country | US
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Telephone | 970-520-0738
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Fax |
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL COUNSELOR
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Name | JAMIE DAWN SOUCIE
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Credential | MS, LPC
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Telephone | 970-520-0738
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State | CO
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