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General NPI Number Information
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NPI Number | 1568948776
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Entity Type | Organization
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Legal Business Name | LAKESIDE PSYCHOLOGICAL SERVICES, LLC
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Dates
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Enumeration Date | 07/11/2018
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Last Update Date | 07/23/2018
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Provider Practice Location Address
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Address Line | 3154 LAKESIDE DR APT 103
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City | GRAND JUNCTION
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State | CO
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Zip | 81506
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Country | US
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Telephone | 970-462-7206
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Fax | 970-628-4207
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Provider Business Mailing Address
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Address Line | 915 LAKESIDE CT
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City | GRAND JUNCTION
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State | CO
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Zip | 81506-2815
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. ROGER MILLER
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Credential | PH.D.
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Telephone | 970-462-7206
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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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