Provider Demographics
NPI:1952707598
Name:LAKESIDE EDUCATIONAL SEMINARS AND SERVICES
Entity Type:Organization
Organization Name:LAKESIDE EDUCATIONAL SEMINARS AND SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MALONEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW
Authorized Official - Phone:205-471-5388
Mailing Address - Street 1:2101 3RD AVE S
Mailing Address - Street 2:UNIT 411
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35502-5001
Mailing Address - Country:US
Mailing Address - Phone:205-471-5388
Mailing Address - Fax:205-208-1709
Practice Address - Street 1:3400 HIGHWAY 78 E
Practice Address - Street 2:DR MALONEY NEXT TO SENIOR CARE
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8907
Practice Address - Country:US
Practice Address - Phone:205-471-5388
Practice Address - Fax:205-208-1709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2349C251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1021803124Medicare NSC