Provider Demographics
NPI:1902043672
Name:SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC.
Entity Type:Organization
Organization Name:SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC.
Other - Org Name:REGIONAL MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-472-7396
Mailing Address - Street 1:8400 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6385
Mailing Address - Country:US
Mailing Address - Phone:219-757-1928
Mailing Address - Fax:
Practice Address - Street 1:8555 TAFT ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6123
Practice Address - Country:US
Practice Address - Phone:219-769-4005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100157670BMedicaid