Healthcare Provider Details

I. General information

NPI: 1033984901
Provider Name (Legal Business Name): LAKESHORE COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 09/27/2025
Certification Date: 09/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 S 2000 W STE A105
SYRACUSE UT
84075-9612
US

IV. Provider business mailing address

780 S 2000 W STE A105
SYRACUSE UT
84075-9612
US

V. Phone/Fax

Practice location:
  • Phone: 385-240-1612
  • Fax:
Mailing address:
  • Phone: 385-240-1612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MONICA COOK
Title or Position: OWNER
Credential: LCSW
Phone: 385-240-1612