Lakes Psychological Practice, LLC

Primary specialty

PsychologistTaxonomy code 103T00000X

License

LP5667 Issued in MN

Legal business name

LAKES PSYCHOLOGICAL PRACTICE, LLC

Practice address

100 Fuller St S
Shakopee, MN 55379-1348

Phone

(612) 568-1475

NPI assigned

Jan 10, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Anisa Sophia Mohammed, PSYD, LP

Title

Psychologist

Phone

(612) 568-1475

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1515542400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1515542400000",
    "number": "1194232264",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3248 STEVENS AVE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554083214",
            "telephone_number": "813-401-7624"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 FULLER ST S",
            "city": "SHAKOPEE",
            "state": "MN",
            "postal_code": "553791348",
            "telephone_number": "612-568-1475"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKES PSYCHOLOGICAL PRACTICE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-01-10",
        "last_updated": "2018-01-10",
        "status": "A",
        "authorized_official_last_name": "MOHAMMED",
        "authorized_official_first_name": "ANISA",
        "authorized_official_middle_name": "SOPHIA",
        "authorized_official_title_or_position": "PSYCHOLOGIST",
        "authorized_official_telephone_number": "612-568-1475",
        "authorized_official_credential": "PSYD, LP"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist",
            "state": "MN",
            "license": "LP5667",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1215364625",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.