Provider Demographics
NPI:1780389189
Name:LAKEVIEW WELLNESS LLC
Entity type:Organization
Organization Name:LAKEVIEW WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:763-760-2134
Mailing Address - Street 1:408 3RD ST STE 107
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-1355
Mailing Address - Country:US
Mailing Address - Phone:507-649-2507
Mailing Address - Fax:651-390-6136
Practice Address - Street 1:408 3RD ST STE 107
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-1355
Practice Address - Country:US
Practice Address - Phone:176-376-0213
Practice Address - Fax:651-390-6136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-04
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No251B00000XAgenciesCase Management