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General NPI Number Information
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NPI Number | 1689186587
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Entity Type | Organization
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Legal Business Name | LIFE TRANSFORMATIONS
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Dates
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Enumeration Date | 10/31/2017
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 227 6TH ST N
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City | BRECKENRIDGE
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State | MN
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Zip | 56520-1503
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Country | US
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Telephone | 701-640-8915
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 703
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City | FERGUS FALLS
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State | MN
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Zip | 56538-0703
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/ADDICTION COUNSELOR
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Name | MATA PETESON
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Credential |
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Telephone | 701-640-8915
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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