Provider Demographics
NPI:1922285113
Name:LAKESHORE PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:LAKESHORE PSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:DIANA
Authorized Official - Last Name:MILAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:616-502-9064
Mailing Address - Street 1:17215 ROLLING DUNES DR
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-9512
Mailing Address - Country:US
Mailing Address - Phone:616-502-9064
Mailing Address - Fax:616-844-5099
Practice Address - Street 1:1325 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1813
Practice Address - Country:US
Practice Address - Phone:231-737-8446
Practice Address - Fax:231-737-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009500251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health