Healthcare Provider Details

I. General information

NPI: 1629900444
Provider Name (Legal Business Name): LAKE SUBSTANCE ABUSE SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1143 FAIRWAY ST STE 103
BOWLING GREEN KY
42103-2452
US

IV. Provider business mailing address

1143 FAIRWAY ST STE 103
BOWLING GREEN KY
42103-2452
US

V. Phone/Fax

Practice location:
  • Phone: 812-901-6881
  • Fax: 812-285-8392
Mailing address:
  • Phone: 812-901-6881
  • Fax: 812-285-8392

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: DAVID CORDDRY
Title or Position: OWNER
Credential:
Phone: 407-622-8086