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General NPI Number Information
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NPI Number | 1164205159
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Entity Type | Organization
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Legal Business Name | LAKE'S EDGE THERAPY SERVICES LLC
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Dates
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Enumeration Date | 08/15/2023
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Last Update Date | 08/26/2023
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Provider Practice Location Address
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Address Line | 212 1/2 WASHINGTON AVE STE 3
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City | GRAND HAVEN
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State | MI
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Zip | 49417-3316
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Country | US
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Telephone | 616-419-8591
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Fax |
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Provider Business Mailing Address
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Address Line | 59 N DIVISION AVE
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City | HOLLAND
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State | MI
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Zip | 49424-6456
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Country | US
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Telephone | 616-502-4586
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CATHERINE ANNE KOLACZ
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Credential | LMSW
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Telephone | 616-502-4586
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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