Organization
LAKESIDE PSYCHOLOGICAL SERVICES
Active
Organization
LAKESIDE PSYCHOLOGICAL SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
COREEN ELLEN LAUSENG (BILLING AGENT)
(952) 935-1961
Entity
Organization
Contact information
Practice address
2618 EMERALD DR, GRAND RAPIDS, MN 55744-5060
(218) 327-9013
(218) 327-9013
Mailing address
2618 EMERALD DR, GRAND RAPIDS, MN 55744-5060
(218) 327-9013
(218) 327-9013
Taxonomy
Speciality
Code
Description
License number
State
103TC1900X
Counseling Psychologist
Primary
—
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
8G811GR
BLUE CROSS BLUE SHIELD MN
MN
Enumeration date
09/16/2006
Last updated
08/22/2020
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