Provider Demographics
NPI:1336316207
Name:MOUNTAIN LAKE COUNSELING AND SUPPORT SERVICES, INC.
Entity Type:Organization
Organization Name:MOUNTAIN LAKE COUNSELING AND SUPPORT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:M. MIKELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-597-3553
Mailing Address - Street 1:804 AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8200
Mailing Address - Country:US
Mailing Address - Phone:208-597-3553
Mailing Address - Fax:
Practice Address - Street 1:804 AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-8200
Practice Address - Country:US
Practice Address - Phone:208-597-3553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3664101YP2500X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty