Provider Demographics
NPI:1316450554
Name:LAKESIDE COUNSELING LLC
Entity type:Organization
Organization Name:LAKESIDE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:YEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:859-457-1254
Mailing Address - Street 1:8847 STONE HARBOUR LOOP
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-6324
Mailing Address - Country:US
Mailing Address - Phone:859-457-1254
Mailing Address - Fax:
Practice Address - Street 1:3890 E STATE ROAD 64 UNIT 1
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9040
Practice Address - Country:US
Practice Address - Phone:859-457-1254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14719261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)