Basic Information
| Provider Information | |||||||||
| NPI: | 1982918124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LT RESOURCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 COUNTY ROAD R | ||||||||
| Address2: | PO BOX 271 | ||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546155129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849477 | ||||||||
| FaxNumber: | 7152845547 | ||||||||
| Practice Location | |||||||||
| Address1: | 409 COUNTY ROAD R | ||||||||
| Address2: | |||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546155129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849477 | ||||||||
| FaxNumber: | 7152845547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2010 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | HOORNSTRA | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | LIANE | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOTHERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7152849477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 15427131 | WI | N | Agencies | Community/Behavioral Health | 251S00000X | 3117125 | WI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 42254300 | 05 | WI | MEDICAID |