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General NPI Number Information
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NPI Number | 1619494168
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Entity Type | Organization
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Legal Business Name | LAKESIDE MENTAL HEALTH, PLLC
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Dates
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Enumeration Date | 08/25/2017
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Last Update Date | 08/25/2017
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Provider Practice Location Address
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Address Line | 104 CHARLES ELDRIDGE DRIVE STE 1
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City | LAKEVILLE
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State | MA
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Zip | 02347-1388
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Country | US
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Telephone | 774-213-9332
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Fax |
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Provider Business Mailing Address
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Address Line | 104 CHARLES ELDRIDGE DRIVE STE 1
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City | LAKEVILLE
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State | MA
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Zip | 02347
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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 | OWNER/ NURSE PRACTITIONER
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Name | MRS. EMILY-ROSE MONTGOMERY VIRDEN
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Credential | PMHNP-BC
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Telephone | 774-213-9332
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 2992320
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License Number State | MA
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