MEDICARE: INTEGRATED LIFE COUNSELING CENTER, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	CC00241	MN
2	106H00000X	Marriage & Family Therapist	920	MN
3	106H00000X	Marriage & Family Therapist	2005	MN
4	103TC0700X	Clinical Psychologist	LP3782	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649644634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED LIFE COUNSELING CENTER, PLLC

Provider Business Mailing Address
First Line	:	8931 33RD STREET N
Second Line	:
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-8900
Country	:	US
Telephone Number	:	651-242-9608
Fax Number	:	651-756-8138

Provider Business Practice Location Address
First Line	:	8931 33RD STREET N
Second Line	:
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-8900
Country	:	US
Telephone Number	:	651-242-9608
Fax Number	:	651-756-8138

Authorized Official
Title or Position	:	DIRECTOR OF COMMUNICATIONS
Name	:	MS. TRACY LEE KAYE SWANSON
Credential	:	LPCC
Telephone Number	:	651-242-9608

Provider Enumeration Date	:	11/14/2015
Last Update Date	:	09/02/2016

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