Provider Demographics
NPI:1124598669
Name:LAKE SUBSTANCE ABUSE SOLUTIONS LLC
Entity Type:Organization
Organization Name:LAKE SUBSTANCE ABUSE SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-622-8086
Mailing Address - Street 1:225 W CANTON AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3181
Mailing Address - Country:US
Mailing Address - Phone:407-622-8086
Mailing Address - Fax:
Practice Address - Street 1:1507 SPRING ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-2939
Practice Address - Country:US
Practice Address - Phone:833-525-3727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Multi-Specialty
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty