Healthcare Provider Details

I. General information

NPI: 1932983210
Provider Name (Legal Business Name): LAKE SHORE THERAPY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 SKOKIE BLVD STE 240
NORTHBROOK IL
60062-4022
US

IV. Provider business mailing address

899 SKOKIE BLVD STE 240
NORTHBROOK IL
60062-4022
US

V. Phone/Fax

Practice location:
  • Phone: 815-496-0620
  • Fax:
Mailing address:
  • Phone: 312-772-4768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN COLLEDGE
Title or Position: THERAPIST
Credential: LCPC
Phone: 330-858-3312