Provider Demographics
NPI:1316024847
Name:LAKEFRONT WELLNESS CENTER, SC
Entity type:Organization
Organization Name:LAKEFRONT WELLNESS CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:262-695-8857
Mailing Address - Street 1:161 W WISCONSIN AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3468
Mailing Address - Country:US
Mailing Address - Phone:262-695-8857
Mailing Address - Fax:262-695-8879
Practice Address - Street 1:161 W WISCONSIN AVE STE 2B
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3468
Practice Address - Country:US
Practice Address - Phone:262-695-8857
Practice Address - Fax:262-695-8879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2437101YM0800X, 103T00000X, 1041C0700X, 106H00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42230900Medicaid
WI42230900Medicaid