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General NPI Number Information
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NPI Number | 1972873420
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Entity Type | Organization
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Legal Business Name | OPTIMISTIC LIVING COUNSELING, LLC
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Dates
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Enumeration Date | 12/30/2011
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Last Update Date | 03/22/2019
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Provider Practice Location Address
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Address Line | 10904 57TH ST NE STE 106
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City | ALBERTVILLE
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State | MN
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Zip | 55301-4654
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Country | US
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Telephone | 763-497-0733
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Fax | 763-497-0728
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Provider Business Mailing Address
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Address Line | 10904 57TH ST NE STE 106
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City | ALBERTVILLE
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State | MN
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Zip | 55301-4654
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Country | US
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Telephone | 763-497-0733
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Fax | 763-497-0728
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. MICHELLE ANN CLARK
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Credential | MA, LMFT
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Telephone | 763-497-0733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 2110
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License Number State | MN
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