Provider Demographics
NPI:1396089660
Name:LAKE SUPERIOR PSYCHOLOGICAL SERVICES, INC.
Entity type:Organization
Organization Name:LAKE SUPERIOR PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D, LP
Authorized Official - Phone:218-722-2525
Mailing Address - Street 1:4891 MILLER TRUNK HWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1512
Mailing Address - Country:US
Mailing Address - Phone:218-722-2525
Mailing Address - Fax:218-722-1033
Practice Address - Street 1:4891 MILLER TRUNK HWY
Practice Address - Street 2:SUITE 106
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1512
Practice Address - Country:US
Practice Address - Phone:218-722-2525
Practice Address - Fax:218-722-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4532251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health