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General NPI Number Information
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NPI Number | 1114484847
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Entity Type | Organization
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Legal Business Name | LAKE REGION THERAPEUTIC SERVICES INC
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Dates
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Enumeration Date | 02/28/2019
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Last Update Date | 09/13/2023
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Provider Practice Location Address
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Address Line | 1007 MAINSTREET
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City | HOPKINS
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State | MN
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Zip | 55343-7517
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Country | US
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Telephone | 952-456-6352
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Fax | 952-303-3104
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Provider Business Mailing Address
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Address Line | 3055 OLD HIGHWAY 8 STE 347
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City | SAINT ANTHONY
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State | MN
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Zip | 55418-2500
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Country | US
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Telephone | 952-657-0884
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ABDIRAZAQ IBRAHIM
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Credential |
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Telephone | 602-323-4873
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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