Organization
LAKESIDE FAMILY THERAPY SERVICES LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACQUELINE V MCRAE (PRESIDENT)
(262) 637-9984
Entity
Organization
Contact information
Practice address
4810 NORTHWESTERN AVE, RACINE, WI 53406
(262) 637-9984
(262) 637-9995
Mailing address
4810 NORTHWESTERN AVE, RACINE, WI 53406-1504
(262) 637-9984
(262) 637-9995
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YM0800X
Mental Health Counselor
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
261QM1300X
Multi-Specialty Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42120700
—
WI
Enumeration date
02/13/2007
Last updated
08/06/2021
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