Provider Demographics
NPI:1699332106
Name:LAKEWOOD RANCH COUNSELING
Entity type:Organization
Organization Name:LAKEWOOD RANCH COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:941-549-1521
Mailing Address - Street 1:21705 67TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-7089
Mailing Address - Country:US
Mailing Address - Phone:941-549-1521
Mailing Address - Fax:
Practice Address - Street 1:8636 STATE ROAD 70 E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-3785
Practice Address - Country:US
Practice Address - Phone:941-549-1521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty