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General NPI Number Information
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NPI Number | 1861262651
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Entity Type | Organization
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Legal Business Name | LAKE COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 01/03/2024
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 620 S IDAHO AVE
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City | FRUITLAND
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State | ID
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Zip | 83619-2607
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Country | US
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Telephone | 208-739-6121
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Fax |
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Provider Business Mailing Address
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Address Line | 2719 DOGWOOD AVE
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City | FRUITLAND
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State | ID
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Zip | 83619-5067
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Country | US
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Telephone | 208-739-6121
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHRISTA LAKE
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Credential | LPC
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Telephone | 208-739-6121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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