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NPI Code Detail

MEDICARE: LAKE MICHIGAN PSYCHOTHERAPY SERVICES, PLLC

MEDICARE: LAKE MICHIGAN PSYCHOTHERAPY SERVICES, PLLC
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
1101YP2500XProfessional Counselor

General Provider Information

NPI Number : 1730036823
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKE MICHIGAN PSYCHOTHERAPY SERVICES, PLLC
Provider Business Mailing Address
First Line : 4050 N LINCOLN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60618-3067
Country : US
Telephone Number : 773-257-3017
Fax Number :
Provider Business Practice Location Address
First Line : 4050 N LINCOLN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60618-3067
Country : US
Telephone Number : 773-257-3017
Fax Number :
Authorized Official
Title or Position : OWNER
Name : RYAN MICHELSEN
Credential : LCPC
Telephone Number : 773-257-3017
Provider Enumeration Date : 03/16/2026
Last Update Date : 03/16/2026

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