=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649783697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE EFFECT PSYCHOTHERAPY GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2017
-----------------------------------------------------
Last Update Date | 11/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 W 2ND ST STE 300
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55802-1920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-228-0035
-----------------------------------------------------
Fax | 218-304-7862
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 W 2ND ST STE 300
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55802-1920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-228-0035
-----------------------------------------------------
Fax | 218-304-7862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DANA LOUISE GARBERG
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 218-228-0035
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------