Healthcare Provider Details

I. General information

NPI: 1659207694
Provider Name (Legal Business Name): LAKESHORE PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6117 N WINTHROP AVE APT 3N
CHICAGO IL
60660-2773
US

IV. Provider business mailing address

2501 CHATHAM RD STE N
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 224-509-9351
  • Fax: 773-825-8338
Mailing address:
  • Phone: 224-509-9351
  • Fax: 773-825-8338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHAD CARSON
Title or Position: OWNER
Credential: APRN, PMHNP-BC
Phone: 224-509-9351