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General NPI Number Information
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NPI Number | 1760892244
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Entity Type | Organization
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Legal Business Name | INTENTIONAL SELF COUNSELING, COACHING, AND CONSULTATION
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Dates
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Enumeration Date | 05/05/2014
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Last Update Date | 05/05/2014
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Provider Practice Location Address
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Address Line | 1154 GRAND AVE STE 2
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City | SAINT PAUL
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State | MN
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Zip | 55105-2628
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Country | US
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Telephone | 763-228-4752
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Fax |
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Provider Business Mailing Address
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Address Line | 2547 DAHL AVE E MAPLEWOOD
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City | SAINT PAUL
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State | MN
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Zip | 55119-6500
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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
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Name | TARA LEMKE EBENHOCH
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Credential | LMFT
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Telephone | 763-228-4752
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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 | 1939
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License Number State | MN
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