=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245742469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE ERIE BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2017
-----------------------------------------------------
Last Update Date | 11/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3216 STATE ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-812-2633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3216 STATE ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16508-2822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-454-3192
-----------------------------------------------------
Fax | 814-454-3190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SHERIFIA ELAINE HERON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 814-454-3192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | MD458004
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------