Provider Demographics
NPI:1972092047
Name:SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC.
Entity Type:Organization
Organization Name:SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC.
Other - Org Name:
Other - Org Type:
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:219-757-1924
Mailing Address - Fax:219-757-1950
Practice Address - Street 1:3903 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312
Practice Address - Country:US
Practice Address - Phone:219-398-7050
Practice Address - Fax:219-392-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN424-014261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder