MEDICARE: LAKESIDE COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1457045452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE COUNSELING

Provider Business Mailing Address
First Line	:	2073 W WAYZATA BLVD STE 200
Second Line	:
City	:	LONG LAKE
State	:	MN
Zip	:	55356-4520
Country	:	US
Telephone Number	:	414-530-0884
Fax Number	:

Provider Business Practice Location Address
First Line	:	2073 W WAYZATA BLVD STE 200
Second Line	:
City	:	LONG LAKE
State	:	MN
Zip	:	55356-4520
Country	:	US
Telephone Number	:	414-530-0884
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATHRYN MULLER
Credential	:	MA
Telephone Number	:	414-530-0884

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	06/05/2023

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Directions to “LAKESIDE COUNSELING ” Practice Location

Language	Start Address	Practice Location

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