Provider Demographics
NPI:1053702910
Name:ACRES FOR LIFE THERAPY & WELLNESS CENTER
Entity type:Organization
Organization Name:ACRES FOR LIFE THERAPY & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-257-4159
Mailing Address - Street 1:11720 256TH ST
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-9752
Mailing Address - Country:US
Mailing Address - Phone:651-257-4159
Mailing Address - Fax:
Practice Address - Street 1:11720 256TH ST
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9752
Practice Address - Country:US
Practice Address - Phone:651-257-4159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302220101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty