Provider Demographics
NPI:1194232264
Name:LAKES PSYCHOLOGICAL PRACTICE, LLC
Entity type:Organization
Organization Name:LAKES PSYCHOLOGICAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ANISA
Authorized Official - Middle Name:SOPHIA
Authorized Official - Last Name:MOHAMMED
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:612-568-1475
Mailing Address - Street 1:3248 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3214
Mailing Address - Country:US
Mailing Address - Phone:813-401-7624
Mailing Address - Fax:
Practice Address - Street 1:100 FULLER ST S
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1348
Practice Address - Country:US
Practice Address - Phone:612-568-1475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5667103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1215364625Medicaid