Provider Demographics
NPI:1639371248
Name:LAKESIDE PUBLIC SCHOOLS
Entity Type:Organization
Organization Name:LAKESIDE PUBLIC SCHOOLS
Other - Org Name:LAKESIDE SCHOOL DISTRICT
Other - Org Type:Other Name
Authorized Official - Title/Position:MITS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-367-6848
Mailing Address - Street 1:1022 SCOGIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655
Mailing Address - Country:US
Mailing Address - Phone:870-367-6848
Mailing Address - Fax:870-367-9877
Practice Address - Street 1:1110 SOUTH LAKESHORE DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653
Practice Address - Country:US
Practice Address - Phone:870-367-6848
Practice Address - Fax:870-367-9877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0903235Z00000X
251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No251300000XAgenciesLocal Education Agency (LEA)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116592743Medicaid