Provider Demographics
NPI:1699180901
Name:LAKESHORE THERAPY PLLC
Entity Type:Organization
Organization Name:LAKESHORE THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HELENA
Authorized Official - Middle Name:ESTHER
Authorized Official - Last Name:WITKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:810-689-4846
Mailing Address - Street 1:1017 S LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:CARSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48419-9494
Mailing Address - Country:US
Mailing Address - Phone:810-404-8362
Mailing Address - Fax:810-958-1295
Practice Address - Street 1:51 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1244
Practice Address - Country:US
Practice Address - Phone:810-689-4846
Practice Address - Fax:810-958-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010806011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5004Medicare UPIN