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General NPI Number Information
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NPI Number | 1750651568
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Entity Type | Organization
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Legal Business Name | LAKESIDE RECOVERY CENTER
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Dates
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Enumeration Date | 01/10/2012
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Last Update Date | 10/14/2013
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Provider Practice Location Address
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Address Line | 200 INDEPENDENCE BLVD
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City | SICKLERVILLE
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State | NJ
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Zip | 08081-1092
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Country | US
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Telephone | 856-302-1362
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Fax |
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Provider Business Mailing Address
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Address Line | 200 INDEPENDENCE BLVD
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City | SICKLERVILLE
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State | NJ
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Zip | 08081-1092
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Country | US
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Telephone | 856-302-1362
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Fax |
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Authorized Official
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Title or Position | DIR OF TREATMENT SERVICE
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Name | MS. PHYLLIS WEINSTEIN
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Credential | MSW,MED,LCSW,LPC,LCA
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Telephone | 856-302-1362
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 2000527-11
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License Number State | NJ
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