Provider Demographics
NPI:1114071420
Name:NORTHERN LAKES CLINIC, INC.
Entity Type:Organization
Organization Name:NORTHERN LAKES CLINIC, INC.
Other - Org Name:NORTHERN LAKES CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO & OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:COCHRANE
Authorized Official - Last Name:SCHLUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:952-925-5344
Mailing Address - Street 1:6200 EXCELSIOR BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2730
Mailing Address - Country:US
Mailing Address - Phone:952-925-5344
Mailing Address - Fax:952-548-9350
Practice Address - Street 1:301 AMERICA AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3120
Practice Address - Country:US
Practice Address - Phone:218-755-5170
Practice Address - Fax:218-751-1194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1045771-1-CDT261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder