Healthcare Provider Details

I. General information

NPI: 1487068458
Provider Name (Legal Business Name): LAKESHORE PSYCHOLOGICAL & COUNSELING SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 1/2 S RIVER AVE
HOLLAND MI
49423-3174
US

IV. Provider business mailing address

194 1/2 S RIVER AVE
HOLLAND MI
49423-3174
US

V. Phone/Fax

Practice location:
  • Phone: 616-402-5093
  • Fax:
Mailing address:
  • Phone: 616-402-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301011612
License Number StateMI

VIII. Authorized Official

Name: JAMES DOHERTY
Title or Position: OWNER
Credential: PSYD
Phone: 616-464-1747