Provider Demographics
NPI:1790273308
Name:GREAT LAKES NP OF PSYCHIATRY, PLLC
Entity Type:Organization
Organization Name:GREAT LAKES NP OF PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:716-908-1711
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-0061
Mailing Address - Country:US
Mailing Address - Phone:716-908-1711
Mailing Address - Fax:
Practice Address - Street 1:3802 SENECA ST
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3433
Practice Address - Country:US
Practice Address - Phone:716-677-5418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400896363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty