Provider Demographics
NPI:1023377488
Name:LAKE VICTORIA MENTAL HEALTH SERVICES, PC
Entity Type:Organization
Organization Name:LAKE VICTORIA MENTAL HEALTH SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DIRECTOR, PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:651-724-0497
Mailing Address - Street 1:978 DAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6544
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3405 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-2107
Practice Address - Country:US
Practice Address - Phone:651-724-0497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health