Provider Demographics
NPI:1578756334
Name:LAKE PARK GROUP, LLC
Entity Type:Organization
Organization Name:LAKE PARK GROUP, LLC
Other - Org Name:LAKE PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:COSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-262-5583
Mailing Address - Street 1:2114 W GRANT RD
Mailing Address - Street 2:24
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1141
Mailing Address - Country:US
Mailing Address - Phone:520-365-2025
Mailing Address - Fax:520-365-2027
Practice Address - Street 1:2114 W GRANT RD
Practice Address - Street 2:24
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1141
Practice Address - Country:US
Practice Address - Phone:520-365-2025
Practice Address - Fax:520-365-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251C00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services