Provider Demographics
NPI:1972124980
Name:LAKE GENEVA PSYCHOLOGY, INC.
Entity type:Organization
Organization Name:LAKE GENEVA PSYCHOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOSA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, CEDS
Authorized Official - Phone:305-989-9030
Mailing Address - Street 1:N1330 OVERLAND LN
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-7302
Mailing Address - Country:US
Mailing Address - Phone:305-989-9030
Mailing Address - Fax:
Practice Address - Street 1:630 KENOSHA ST
Practice Address - Street 2:
Practice Address - City:WALWORTH
Practice Address - State:WI
Practice Address - Zip Code:53184-9505
Practice Address - Country:US
Practice Address - Phone:305-989-9030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty