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General NPI Number Information
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NPI Number | 1396089660
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Entity Type | Organization
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Legal Business Name | LAKE SUPERIOR PSYCHOLOGICAL SERVICES, INC.
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Dates
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Enumeration Date | 11/26/2012
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Last Update Date | 02/06/2013
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Provider Practice Location Address
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Address Line | 4891 MILLER TRUNK HWY SUITE 106
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City | HERMANTOWN
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State | MN
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Zip | 55811-1512
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Country | US
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Telephone | 218-722-2525
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Fax | 218-722-1033
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Provider Business Mailing Address
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Address Line | 4891 MILLER TRUNK HWY SUITE 106
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City | HERMANTOWN
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State | MN
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Zip | 55811-1512
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Country | US
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Telephone | 218-722-2525
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Fax | 218-722-1033
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. JEFFREY LYNN OLSON
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Credential | PSY D, LP
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Telephone | 218-722-2525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LP4532
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License Number State | MN
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