Provider Demographics
NPI:1609355452
Name:LAKESHORE WELLNESS AND RECOVERY INC
Entity Type:Organization
Organization Name:LAKESHORE WELLNESS AND RECOVERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:NOWAK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CSAC
Authorized Official - Phone:262-305-9668
Mailing Address - Street 1:1519 E WASHINGTON ST STE A
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2615
Mailing Address - Country:US
Mailing Address - Phone:262-305-9668
Mailing Address - Fax:
Practice Address - Street 1:1519 E WASHINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2615
Practice Address - Country:US
Practice Address - Phone:262-305-9668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15917-132101YA0400X
WI6584-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962748624Medicaid