Organization
LAKEFRONT WELLNESS CENTER, SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BETH A. JOHNSON PSY.D. (DIRECTOR)
(262) 695-8857
Entity
Organization
Contact information
Practice address
161 W WISCONSIN AVE STE 2B, PEWAUKEE, WI 53072-3468
(262) 695-8857
(262) 695-8879
Mailing address
161 W WISCONSIN AVE STE 2B, PEWAUKEE, WI 53072-3468
(262) 695-8857
(262) 695-8879
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
2437
WI
103T00000X
Psychologist
2437
WI
103TC0700X
Clinical Psychologist
Primary
2437
WI
1041C0700X
Clinical Social Worker
2437
WI
106H00000X
Marriage & Family Therapist
2437
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42230900
—
WI
Enumeration date
11/01/2006
Last updated
08/27/2013
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