Healthcare Provider Details

I. General information

NPI: 1881643906
Provider Name (Legal Business Name): LAKESHOREHEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 W MONTROSE AVE
CHICAGO IL
60641-2023
US

IV. Provider business mailing address

4444 W MONTROSE AVE
CHICAGO IL
60641-2023
US

V. Phone/Fax

Practice location:
  • Phone: 773-286-0668
  • Fax: 773-286-0554
Mailing address:
  • Phone: 773-286-0668
  • Fax: 773-286-0554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. JAY SOBLE
Title or Position: SECRETARY
Credential:
Phone: 773-286-0668