Provider Demographics
NPI:1831272574
Name:LAKESHORE PROFESSIONAL COUNSELING INC
Entity type:Organization
Organization Name:LAKESHORE PROFESSIONAL COUNSELING INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:MPS, FT, BCETS, LBSW
Authorized Official - Phone:906-864-2590
Mailing Address - Street 1:447 FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-3307
Mailing Address - Country:US
Mailing Address - Phone:906-864-2590
Mailing Address - Fax:906-864-3058
Practice Address - Street 1:447 FIRST STREET
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-3307
Practice Address - Country:US
Practice Address - Phone:906-864-2590
Practice Address - Fax:906-864-3058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1500251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1500OtherOUTPATIENT MENTAL HEALTH
WI42204000Medicaid