Organization
LIFE INTERRUPTED COUNSELING SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARY L CHEDDA MM, MA, LMFT (CEO/SOLE PROPRIETOR)
(651) 338-8643
Entity
Organization
Contact information
Practice address
1500 MCANDREWS RD W STE 215, BURNSVILLE, MN 55337-4445
(952) 222-3002
Mailing address
1500 MCANDREWS RD W STE 215, BURNSVILLE, MN 55337-4445
(651) 338-8643
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1861931966
INDIVIDUAL NPI
MN
05
—
1861931966
—
MN
Enumeration date
12/15/2022
Last updated
01/18/2024
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