Healthcare Provider Details

I. General information

NPI: 1033505011
Provider Name (Legal Business Name): LAKESIDE BILLING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6280 W 9600 N
HIGHLAND UT
84003-9234
US

IV. Provider business mailing address

6280 W 9600 N
HIGHLAND UT
84003-9234
US

V. Phone/Fax

Practice location:
  • Phone: 801-703-7289
  • Fax: 801-855-7207
Mailing address:
  • Phone: 801-703-7289
  • Fax: 801-855-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateUT

VIII. Authorized Official

Name: JOHANNA SALTER
Title or Position: OWNER
Credential:
Phone: 801-755-4694