Provider Demographics
NPI:1871006817
Name:LAKE COUNTRY COUNSELING LLC
Entity Type:Organization
Organization Name:LAKE COUNTRY COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LIC CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:TESSIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:434-774-7559
Mailing Address - Street 1:516 W ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-1906
Mailing Address - Country:US
Mailing Address - Phone:434-774-7559
Mailing Address - Fax:434-447-3579
Practice Address - Street 1:516 W ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1906
Practice Address - Country:US
Practice Address - Phone:434-774-7559
Practice Address - Fax:434-447-3579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040060711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTIN NUMBER