Provider Demographics
NPI:1407925985
Name:LAKESHORE CLINIC LTD
Entity Type:Organization
Organization Name:LAKESHORE CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BRICENO
Authorized Official - Suffix:
Authorized Official - Credentials:MS LCSW
Authorized Official - Phone:414-962-9909
Mailing Address - Street 1:3970 N OAKLAND AVE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211
Mailing Address - Country:US
Mailing Address - Phone:414-962-9909
Mailing Address - Fax:414-332-8596
Practice Address - Street 1:3970 N OAKLAND AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211
Practice Address - Country:US
Practice Address - Phone:414-962-9909
Practice Address - Fax:414-332-8596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1497261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42106900Medicaid
WI42106900Medicaid