Provider Demographics
NPI:1619494168
Name:LAKESIDE MENTAL HEALTH, PLLC
Entity Type:Organization
Organization Name:LAKESIDE MENTAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY-ROSE
Authorized Official - Middle Name:MONTGOMERY
Authorized Official - Last Name:VIRDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:774-213-9332
Mailing Address - Street 1:104 CHARLES ELDRIDGE DRIVE STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 CHARLES ELDRIDGE DRIVE STE 1
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-1388
Practice Address - Country:US
Practice Address - Phone:774-213-9332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2992320363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty