Provider Demographics
NPI:1881643906
Name:LAKESHOREHEALTHCARE
Entity Type:Organization
Organization Name:LAKESHOREHEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-286-0668
Mailing Address - Street 1:4444 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2023
Mailing Address - Country:US
Mailing Address - Phone:773-286-0668
Mailing Address - Fax:773-286-0554
Practice Address - Street 1:4444 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2023
Practice Address - Country:US
Practice Address - Phone:773-286-0668
Practice Address - Fax:773-286-0554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209756Medicare ID - Type Unspecified