Provider Demographics
NPI:1114484847
Name:LAKE REGION THERAPEUTIC SERVICES INC
Entity Type:Organization
Organization Name:LAKE REGION THERAPEUTIC SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDIRAZAQ
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-323-4873
Mailing Address - Street 1:3055 OLD HIGHWAY 8 STE 347
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2500
Mailing Address - Country:US
Mailing Address - Phone:952-657-0884
Mailing Address - Fax:
Practice Address - Street 1:1007 MAINSTREET
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-7517
Practice Address - Country:US
Practice Address - Phone:952-456-6352
Practice Address - Fax:952-303-3104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-28
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2884Medicaid