Provider Demographics
NPI:1952635716
Name:LAKEWOOD CHILD AND FAMILY COUNSELING LLC
Entity Type:Organization
Organization Name:LAKEWOOD CHILD AND FAMILY COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KLEKOTA-CHISHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC
Authorized Official - Phone:253-617-3559
Mailing Address - Street 1:5409 100TH ST SW UNIT 98765
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98496-0836
Mailing Address - Country:US
Mailing Address - Phone:253-617-3559
Mailing Address - Fax:
Practice Address - Street 1:9311 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1570
Practice Address - Country:US
Practice Address - Phone:253-617-3559
Practice Address - Fax:253-486-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60231172101Y00000X, 101YM0800X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty