MEDICARE: LAKESHOREHEALTHCARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP2701X	Group Psychotherapy Psychologist

General Provider Information

NPI Number	:	1881643906
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESHOREHEALTHCARE

Provider Business Mailing Address
First Line	:	4444 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2023
Country	:	US
Telephone Number	:	773-286-0668
Fax Number	:	773-286-0554

Provider Business Practice Location Address
First Line	:	4444 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2023
Country	:	US
Telephone Number	:	773-286-0668
Fax Number	:	773-286-0554

Authorized Official
Title or Position	:	SECRETARY
Name	:	MR. JAY SOBLE
Credential	:
Telephone Number	:	773-286-0668

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	08/22/2020

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Directions to “LAKESHOREHEALTHCARE ” Practice Location

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