Provider Demographics
NPI:1508927658
Name:LAKESHORE PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:LAKESHORE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:586-777-0470
Mailing Address - Street 1:22811 GREATER MACK AVE
Mailing Address - Street 2:SUITE L-3
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2021
Mailing Address - Country:US
Mailing Address - Phone:586-777-0470
Mailing Address - Fax:
Practice Address - Street 1:22811 GREATER MACK AVE
Practice Address - Street 2:SUITE L-3
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2021
Practice Address - Country:US
Practice Address - Phone:586-777-0470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherEIN