Healthcare Provider Details

I. General information

NPI: 1831272574
Provider Name (Legal Business Name): LAKESHORE PROFESSIONAL COUNSELING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 FIRST STREET
MENOMINEE MI
49858-3307
US

IV. Provider business mailing address

447 FIRST STREET
MENOMINEE MI
49858-3307
US

V. Phone/Fax

Practice location:
  • Phone: 906-864-2590
  • Fax: 906-864-3058
Mailing address:
  • Phone: 906-864-2590
  • Fax: 906-864-3058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1500
License Number StateWI

VIII. Authorized Official

Name: JEANNE M HARPER
Title or Position: CLINIC DIRECTOR
Credential: MPS, FT, BCETS, LBSW
Phone: 906-864-2590