Provider Demographics
NPI:1609943380
Name:SOUTHLAKE SPEECH & HEARING CENTER, INC
Entity Type:Organization
Organization Name:SOUTHLAKE SPEECH & HEARING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JACLIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-A
Authorized Official - Phone:219-738-2528
Mailing Address - Street 1:99 E 86TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6381
Mailing Address - Country:US
Mailing Address - Phone:219-738-2528
Mailing Address - Fax:219-756-7825
Practice Address - Street 1:99 E 86TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6381
Practice Address - Country:US
Practice Address - Phone:219-738-2528
Practice Address - Fax:219-756-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN481-20231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100466380AMedicaid
IN458840Medicare UPIN