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General NPI Number Information
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NPI Number | 1962157826
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Entity Type | Organization
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Legal Business Name | LAKE COUNTRY THERAPIST
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Dates
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Enumeration Date | 02/18/2022
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Last Update Date | 04/06/2022
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Provider Practice Location Address
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Address Line | 354 COTTONWOOD AVE STE C
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City | HARTLAND
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State | WI
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Zip | 53029-2011
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Country | US
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Telephone | 262-290-3163
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Fax |
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Provider Business Mailing Address
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Address Line | N8263 WOODY LN
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City | IXONIA
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State | WI
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Zip | 53036
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Country | US
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Telephone | 414-405-5067
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NICOLE DRAKE
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Credential | LCSW
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Telephone | 414-405-5067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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