Provider Demographics
NPI:1164205159
Name:LAKE'S EDGE THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:LAKE'S EDGE THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KOLACZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-502-4586
Mailing Address - Street 1:59 N DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-6456
Mailing Address - Country:US
Mailing Address - Phone:616-502-4586
Mailing Address - Fax:
Practice Address - Street 1:212 1/2 WASHINGTON AVE STE 3
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-3316
Practice Address - Country:US
Practice Address - Phone:616-419-8591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-15
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty