Healthcare Provider Details

I. General information

NPI: 1982842167
Provider Name (Legal Business Name): LAKES CENTER FOR YOUTH AND FAMILIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 N LAKE STREET SUITE 103
FOREST LAKE MN
55025
US

IV. Provider business mailing address

20 N LAKE STREET SUITE 103
FOREST LAKE MN
55025
US

V. Phone/Fax

Practice location:
  • Phone: 651-464-3685
  • Fax: 651-464-3687
Mailing address:
  • Phone: 651-464-3685
  • Fax: 651-464-3687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1179
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1946
License Number StateMN

VIII. Authorized Official

Name: DR. LINDA M MADSEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 651-464-3685