Provider Demographics
NPI:1275908097
Name:THE COTTAGE OF LAKEWAY
Entity Type:Organization
Organization Name:THE COTTAGE OF LAKEWAY
Other - Org Name:THE LAKEHOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:214-669-1002
Mailing Address - Street 1:1150 LAKEWAY DR
Mailing Address - Street 2:SUITE 216
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78234
Mailing Address - Country:US
Mailing Address - Phone:512-692-9252
Mailing Address - Fax:
Practice Address - Street 1:2777 TRADEWIND DR
Practice Address - Street 2:
Practice Address - City:SPICEWOOD
Practice Address - State:TX
Practice Address - Zip Code:78669-5131
Practice Address - Country:US
Practice Address - Phone:214-669-1002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63830101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty