MEDICARE: LAKESIDE MENTAL HEALTH, 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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2992320	MA

General Provider Information

NPI Number	:	1619494168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE MENTAL HEALTH, PLLC

Provider Business Mailing Address
First Line	:	104 CHARLES ELDRIDGE DRIVE STE 1
Second Line	:
City	:	LAKEVILLE
State	:	MA
Zip	:	02347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 CHARLES ELDRIDGE DRIVE STE 1
Second Line	:
City	:	LAKEVILLE
State	:	MA
Zip	:	02347-1388
Country	:	US
Telephone Number	:	774-213-9332
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ NURSE PRACTITIONER
Name	:	MRS. EMILY-ROSE MONTGOMERY VIRDEN
Credential	:	PMHNP-BC
Telephone Number	:	774-213-9332

Provider Enumeration Date	:	08/25/2017
Last Update Date	:	08/25/2017

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