Provider Demographics
NPI:1699179994
Name:LAKESHORE FAMILY THERAPY, LLC
Entity Type:Organization
Organization Name:LAKESHORE FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:651-231-7471
Mailing Address - Street 1:3701 SHORELINE DR STE 102A
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-4000
Mailing Address - Country:US
Mailing Address - Phone:651-231-7471
Mailing Address - Fax:
Practice Address - Street 1:3701 SHORELINE DR STE 102A
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4000
Practice Address - Country:US
Practice Address - Phone:651-231-7471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2494106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty