Provider Demographics
NPI:1831328533
Name:LAKE COUNTRY COUNSELING SERVICE
Entity type:Organization
Organization Name:LAKE COUNTRY COUNSELING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHILD AND FAMILY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:262-691-2982
Mailing Address - Street 1:325 FOREST GROVE DR
Mailing Address - Street 2:STE. 201
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3793
Mailing Address - Country:US
Mailing Address - Phone:262-719-9470
Mailing Address - Fax:262-691-2972
Practice Address - Street 1:325 FOREST GROVE DR
Practice Address - Street 2:STE. 201
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3793
Practice Address - Country:US
Practice Address - Phone:262-719-9470
Practice Address - Fax:262-691-2972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3487125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty