Provider Demographics
NPI:1346424520
Name:LAKE SHORE BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:LAKE SHORE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HITZEL
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:716-842-0440
Mailing Address - Street 1:430 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-1886
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:716-842-4069
Practice Address - Street 1:LAKE SHORE BEHAVIORAL HEALTH
Practice Address - Street 2:254 FRANKLIN STREET
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202
Practice Address - Country:US
Practice Address - Phone:716-842-0440
Practice Address - Fax:716-842-4069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02732658261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMMIS#02732658OtherRISPERDAL CONSTA