Provider Demographics
NPI:1447644471
Name:LAKESHORE INTEGRATIVE MENTAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:LAKESHORE INTEGRATIVE MENTAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BRUURSEMA
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, ACSW
Authorized Official - Phone:231-799-4850
Mailing Address - Street 1:800 E ELLIS RD
Mailing Address - Street 2:MAIL BOX 577, SUITE 271
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5646
Mailing Address - Country:US
Mailing Address - Phone:231-799-4850
Mailing Address - Fax:231-799-4851
Practice Address - Street 1:800 E ELLIS RD
Practice Address - Street 2:MAIL BOX 577, SUITE 271
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49441-5646
Practice Address - Country:US
Practice Address - Phone:231-799-4850
Practice Address - Fax:231-799-4851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOGO6004048Medicare PIN