Organization · NPI-2

Lakeside Family Therapy Services Ltd

Clinic/Center, Mental Health (Including Community Mental Health Center) · Racine, WI

NPI number1407998719

StatusActive

Last updated in NPPESAug 6, 2021

Details

NPI: 1407998719
Entity type: Organization (NPI-2)
Legal business name: Lakeside Family Therapy Services Ltd
Organization subpart: No
Enumeration date: Feb 13, 2007
Certification date: Aug 6, 2021
Last updated: Aug 6, 2021

Taxonomy and licenses

Taxonomy code	Description	License	State	Primary
261QM0801X	Clinic/Center, Mental Health (Including Community Mental Health Center)	–	–	Yes
101YA0400X	Counselor, Addiction (Substance Use Disorder)	–	–
101YM0800X	Counselor, Mental Health	–	–
261QM1300X	Clinic/Center, Multi-Specialty	–	–

Practice location

4810 Northwestern Ave
Racine, WI 53406

Phone 262-637-9984 · Fax 262-637-9995

Mailing address

4810 Northwestern Ave
Racine, WI 53406-1504

Phone 262-637-9984 · Fax 262-637-9995

Authorized official

Jacqueline V Mcrae
President
2626379984

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