Provider Demographics
NPI:1043697832
Name:LAKESIDE CENTER
Entity Type:Organization
Organization Name:LAKESIDE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEITCH-ALFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:757-874-0468
Mailing Address - Street 1:PO BOX 13296
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-0296
Mailing Address - Country:US
Mailing Address - Phone:757-714-1838
Mailing Address - Fax:757-321-6269
Practice Address - Street 1:6515 GEORGE WASHINGTON MEM HWY
Practice Address - Street 2:# 101
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692-2182
Practice Address - Country:US
Practice Address - Phone:757-714-1838
Practice Address - Fax:757-321-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty