Provider Demographics
NPI:1558744326
Name:LAKESHORE PSYCHOLOGY GROUP LLC
Entity Type:Organization
Organization Name:LAKESHORE PSYCHOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GEIER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-564-1800
Mailing Address - Street 1:320 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-2056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 SKOKIE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2851
Practice Address - Country:US
Practice Address - Phone:847-564-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty