MEDICARE: LAKES AREA HUMAN SERVICES, INC.

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	251S00000X	Community/Behavioral Health Agency	4454726	MN

General Provider Information

NPI Number	:	1700956646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES AREA HUMAN SERVICES, INC.

Provider Business Mailing Address
First Line	:	882 SW 15TH ST.
Second Line	:
City	:	FORESST LAKE
State	:	MN
Zip	:	55025-1331
Country	:	US
Telephone Number	:	651-464-2194
Fax Number	:	651-464-5744

Provider Business Practice Location Address
First Line	:	882 SW 15TH ST.
Second Line	:
City	:	FOREST LAKE
State	:	MN
Zip	:	55025-1331
Country	:	US
Telephone Number	:	651-464-2194
Fax Number	:	651-464-5744

Authorized Official
Title or Position	:	ADMOMNISTRATIVE DIRECTOR
Name	:	MS. CHARLOTTE LOUISE STACK
Credential	:	RN, CNS,ARNP
Telephone Number	:	651-464-2194

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	08/22/2020

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