Provider Demographics
NPI:1013932748
Name:SOUTH SHORE LAKE FRONT SERVICES, INC
Entity Type:Organization
Organization Name:SOUTH SHORE LAKE FRONT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-375-1900
Mailing Address - Street 1:2619 E 75TH ST # 21
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-3705
Mailing Address - Country:US
Mailing Address - Phone:773-375-1900
Mailing Address - Fax:773-785-2091
Practice Address - Street 1:2619 E 75TH ST # 21
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3705
Practice Address - Country:US
Practice Address - Phone:773-375-1900
Practice Address - Fax:773-785-2091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211447Medicare PIN