Provider Demographics
NPI:1316043458
Name:LAKESIDE PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:LAKESIDE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:COREEN
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:LAUSENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-935-1961
Mailing Address - Street 1:2618 EMERALD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-5060
Mailing Address - Country:US
Mailing Address - Phone:218-327-9013
Mailing Address - Fax:218-327-9013
Practice Address - Street 1:2618 EMERALD DR
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-5060
Practice Address - Country:US
Practice Address - Phone:218-327-9013
Practice Address - Fax:218-327-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8G811GROtherBLUE CROSS BLUE SHIELD MN