Provider Demographics
NPI:1255791745
Name:WEST LAKE COUNSELING AND WELLNESS, INC
Entity type:Organization
Organization Name:WEST LAKE COUNSELING AND WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:BAUMAN
Authorized Official - Last Name:MIZUHATA
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-386-2311
Mailing Address - Street 1:470 COUNTY ROAD 110 N
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-8315
Mailing Address - Country:US
Mailing Address - Phone:612-386-2311
Mailing Address - Fax:
Practice Address - Street 1:1613 W WAYZATA BLVD STE B
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-4103
Practice Address - Country:US
Practice Address - Phone:612-386-2311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN180441041C0700X
MN180161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty