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General NPI Number Information
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NPI Number | 1780389189
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Entity Type | Organization
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Legal Business Name | LAKEVIEW WELLNESS LLC
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Dates
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Enumeration Date | 04/04/2023
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 408 3RD ST STE 107
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City | FARMINGTON
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State | MN
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Zip | 55024-1355
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Country | US
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Telephone | 176-376-0213
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Fax | 651-390-6136
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Provider Business Mailing Address
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Address Line | 408 3RD ST STE 107
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City | FARMINGTON
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State | MN
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Zip | 55024-1355
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Country | US
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Telephone | 507-649-2507
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Fax | 651-390-6136
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | TESSA FULTZ
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Credential | LICSW
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Telephone | 763-760-2134
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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