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General NPI Number Information
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NPI Number | 1518625029
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Entity Type | Organization
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Legal Business Name | LAKESIDE HEALING SERVICES, LLC
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Dates
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Enumeration Date | 12/01/2021
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Last Update Date | 12/01/2021
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Provider Practice Location Address
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Address Line | 911 BAYLY RD
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City | CAMBRIDGE
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State | MD
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Zip | 21613-2911
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Country | US
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Telephone | 410-901-7243
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Fax |
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Provider Business Mailing Address
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Address Line | 911 BAYLY RD
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City | CAMBRIDGE
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State | MD
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Zip | 21613-2911
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Country | US
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Telephone | 410-901-7243
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JENNIFER LAKE
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Credential |
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Telephone | 410-901-7243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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