Healthcare Provider Details

I. General information

NPI: 1316043458
Provider Name (Legal Business Name): LAKESIDE PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2618 EMERALD DR
GRAND RAPIDS MN
55744-5060
US

IV. Provider business mailing address

2618 EMERALD DR
GRAND RAPIDS MN
55744-5060
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-9013
  • Fax: 218-327-9013
Mailing address:
  • Phone: 218-327-9013
  • Fax: 218-327-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateMN

VIII. Authorized Official

Name: COREEN ELLEN LAUSENG
Title or Position: BILLING AGENT
Credential:
Phone: 952-935-1961