=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013932748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH SHORE LAKE FRONT SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 02/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2619 E 75TH ST # 21
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60649-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-375-1900
-----------------------------------------------------
Fax | 773-785-2091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2619 E 75TH ST # 21
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60649-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-375-1900
-----------------------------------------------------
Fax | 773-785-2091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. LEONARD GO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-375-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------