Provider Demographics
NPI:1154404325
Name:LAKEVIEW BEHAVIORAL HEALTH INC.
Entity type:Organization
Organization Name:LAKEVIEW BEHAVIORAL HEALTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-327-2001
Mailing Address - Street 1:516 S POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3800
Mailing Address - Country:US
Mailing Address - Phone:218-327-2001
Mailing Address - Fax:218-327-0456
Practice Address - Street 1:516 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3800
Practice Address - Country:US
Practice Address - Phone:218-327-2001
Practice Address - Fax:218-327-0456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN805713-1-CDT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN371225700Medicaid
MN8974RAOtherBLUE CROSS BLUE SHIELD
MN5042493OtherMEDICA
MN122307OtherBEHAVIORAL HEALTH