1396089660 NPI number — LAKE SUPERIOR PSYCHOLOGICAL SERVICES, INC.

Table of content: (NPI 1396089660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396089660 NPI number — LAKE SUPERIOR PSYCHOLOGICAL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE SUPERIOR PSYCHOLOGICAL SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396089660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4891 MILLER TRUNK HWY
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
HERMANTOWN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55811-1512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-722-2525
Provider Business Mailing Address Fax Number:
218-722-1033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4891 MILLER TRUNK HWY
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
HERMANTOWN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55811-1512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-722-2525
Provider Business Practice Location Address Fax Number:
218-722-1033
Provider Enumeration Date:
11/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
OLSON
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
218-722-2525

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  LP4532 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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