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General NPI Number Information
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NPI Number | 1710097274
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Entity Type | Organization
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Legal Business Name | LIFESPAN OF MINNESOTA, INC.
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 12425 RIVER RIDGE BLVD #200
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City | BURNSVILLE
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State | MN
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Zip | 55337-4871
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Country | US
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Telephone | 952-562-8500
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Fax | 952-562-8501
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Provider Business Mailing Address
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Address Line | 12425 RIVER RIDGE BLVD #200
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City | BURNSVILLE
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State | MN
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Zip | 55337-4871
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Country | US
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Telephone | 952-562-8500
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Fax | 952-562-8501
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Authorized Official
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Title or Position | CEO/CLINICAL DIRECTOR
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Name | MRS. TRACI LEE HACKMANN
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Credential | MA LP
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Telephone | 952-562-8500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 7876190 00
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 7076053 00
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License Number State | MN
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