MEDICARE: LAKESIDE PSYCHOLOGICAL SERVICES, LLC

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1568948776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE PSYCHOLOGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	915 LAKESIDE CT
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81506-2815
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3154 LAKESIDE DR APT 103
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81506
Country	:	US
Telephone Number	:	970-462-7206
Fax Number	:	970-628-4207

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. ROGER MILLER
Credential	:	PH.D.
Telephone Number	:	970-462-7206

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	07/23/2018

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