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General NPI Number Information
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NPI Number | 1902177520
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Entity Type | Organization
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Legal Business Name | LAKESIDE FAMILY CENTER
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Dates
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Enumeration Date | 01/13/2012
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Last Update Date | 01/13/2012
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Provider Practice Location Address
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Address Line | 219 N HIGHWAY 52 STE R
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City | MONCKS CORNER
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State | SC
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Zip | 29461-3926
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Country | US
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Telephone | 843-761-3325
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Fax |
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Provider Business Mailing Address
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Address Line | 219 N HIGHWAY 52 STE R
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City | MONCKS CORNER
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State | SC
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Zip | 29461-3926
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Country | US
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Telephone | 843-761-3325
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ELIZABETH LOUISE VINSON
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Credential | MA, LPC
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Telephone | 843-761-3325
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 4776
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License Number State | SC
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