=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134852635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKESHORE PSYCHOLOGICAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2022
-----------------------------------------------------
Last Update Date | 07/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 E ERIE ST STE 525
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-869-9887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 E ERIE ST STE 525-5270
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-2740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | LESLIE RUBIN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 312-869-9887
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------