Organization
LIFESPAN OF MINNESOTA, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. TRACI LEE HACKMANN MA LP (CEO/CLINICAL DIRECTOR)
(952) 562-8500
Entity
Organization
Contact information
Practice address
12425 RIVER RIDGE BLVD, #200, BURNSVILLE, MN 55337-4871
(952) 562-8500
(952) 562-8501
Mailing address
12425 RIVER RIDGE BLVD, #200, BURNSVILLE, MN 55337-4871
(952) 562-8500
(952) 562-8501
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
7076053 00
MN
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
7876190 00
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
100598
HEALTHPARTNERS
MN
01
—
102020
UCARE
MN
01
—
454T4DA
BLUE CROSS BLUE SHIELD
MN
05
—
707605300
—
MN
05
—
787619000
—
MN
Enumeration date
08/30/2006
Last updated
07/21/2022
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