Provider Demographics
NPI:1417557968
Name:LAKE SHORE MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:LAKE SHORE MENTAL HEALTH SERVICES
Other - Org Name:LAKE SHORE MENTAL HEALTH SERVICES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:N
Authorized Official - Last Name:DIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:773-559-0393
Mailing Address - Street 1:3685 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-1625
Mailing Address - Country:US
Mailing Address - Phone:872-201-6911
Mailing Address - Fax:
Practice Address - Street 1:7638 S EVANS AVE STE B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-2519
Practice Address - Country:US
Practice Address - Phone:728-201-6911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL341763684002Medicaid