Provider Demographics
NPI:1023322351
Name:LAKES COUNTRY COUNSELING PLLC
Entity type:Organization
Organization Name:LAKES COUNTRY COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:218-454-0878
Mailing Address - Street 1:7251 EXCELSIOR RD
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425-8477
Mailing Address - Country:US
Mailing Address - Phone:218-454-0878
Mailing Address - Fax:218-454-0879
Practice Address - Street 1:7251 EXCELSIOR RD
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-454-0878
Practice Address - Fax:218-454-0879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1531251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH100336668Medicare PIN