Healthcare Provider Details

I. General information

NPI: 1063237600
Provider Name (Legal Business Name): LAKESIDE LANGUAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 S 3RD ST # 1
ROGERS CITY MI
49779-1710
US

IV. Provider business mailing address

196 S 3RD ST # 1
ROGERS CITY MI
49779-1710
US

V. Phone/Fax

Practice location:
  • Phone: 231-445-5090
  • Fax:
Mailing address:
  • Phone: 231-445-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHELBY CARRIER
Title or Position: OWNER
Credential: SLP
Phone: 231-445-5090