Provider Demographics
NPI:1174006985
Name:LAKESIDE FAMILY COUNSELING & INTERVENTION SERVICES
Entity Type:Organization
Organization Name:LAKESIDE FAMILY COUNSELING & INTERVENTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:805-575-2559
Mailing Address - Street 1:1500 PALMA DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6451
Mailing Address - Country:US
Mailing Address - Phone:805-289-1500
Mailing Address - Fax:805-289-1511
Practice Address - Street 1:1500 PALMA DR
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6451
Practice Address - Country:US
Practice Address - Phone:805-289-1500
Practice Address - Fax:805-289-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-09
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108676106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty