Provider Demographics
NPI:1407998719
Name:LAKESIDE FAMILY THERAPY SERVICES LTD
Entity Type:Organization
Organization Name:LAKESIDE FAMILY THERAPY SERVICES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:V
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-637-9984
Mailing Address - Street 1:4810 NORTHWESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-1504
Mailing Address - Country:US
Mailing Address - Phone:262-637-9984
Mailing Address - Fax:262-637-9995
Practice Address - Street 1:4810 NORTHWESTERN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-637-9984
Practice Address - Fax:262-637-9995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42120700Medicaid
WI000084148Medicare ID - Type Unspecified