Provider Demographics
NPI:1457011371
Name:LAKESIDE MENTAL HEALTH
Entity Type:Organization
Organization Name:LAKESIDE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KATI
Authorized Official - Middle Name:
Authorized Official - Last Name:KLITZKE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:320-640-2980
Mailing Address - Street 1:65506 210TH ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-5744
Mailing Address - Country:US
Mailing Address - Phone:320-640-2980
Mailing Address - Fax:
Practice Address - Street 1:2330 TROOP DR UNIT 101
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4531
Practice Address - Country:US
Practice Address - Phone:320-296-1592
Practice Address - Fax:320-640-3029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1750746715OtherNPI