Provider Demographics
NPI:1497011456
Name:LAKE SHORE CENTER FOR BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:LAKE SHORE CENTER FOR BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PIPKIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:254-776-0400
Mailing Address - Street 1:4555 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1814
Mailing Address - Country:US
Mailing Address - Phone:254-776-0400
Mailing Address - Fax:
Practice Address - Street 1:4555 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-1814
Practice Address - Country:US
Practice Address - Phone:254-776-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9878261QM0850X
TX3023261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder