Provider Demographics
NPI:1811067465
Name:LAKE FENTON HAUS INC
Entity type:Organization
Organization Name:LAKE FENTON HAUS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:EXECUTIVE DIRECTOR
Authorized Official - Phone:810-629-7969
Mailing Address - Street 1:12287 MARGARET DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12287 MARGARET DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430
Practice Address - Country:US
Practice Address - Phone:810-629-7969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities