Healthcare Provider Details

I. General information

NPI: 1790273308
Provider Name (Legal Business Name): GREAT LAKES NP OF PSYCHIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 SENECA ST
WEST SENECA NY
14224-3433
US

IV. Provider business mailing address

PO BOX 61
EAST AMHERST NY
14051-0061
US

V. Phone/Fax

Practice location:
  • Phone: 716-677-5418
  • Fax:
Mailing address:
  • Phone: 716-908-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF400896
License Number StateNY

VIII. Authorized Official

Name: MS. LORRAINE A. LOPEZ
Title or Position: OWNER
Credential: PMHNP
Phone: 716-908-1711