Provider Demographics
NPI:1033312574
Name:LAKESIDE THERAPY GROUP
Entity type:Organization
Organization Name:LAKESIDE THERAPY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER SPEECH THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BASTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC SLP
Authorized Official - Phone:304-844-0099
Mailing Address - Street 1:765 BRIGHTRIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330
Mailing Address - Country:US
Mailing Address - Phone:304-844-0099
Mailing Address - Fax:304-848-0265
Practice Address - Street 1:765 BRIGHTRIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-844-0099
Practice Address - Fax:304-848-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP 0710235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty