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General NPI Number Information
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NPI Number | 1417557968
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Entity Type | Organization
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Legal Business Name | LAKE SHORE MENTAL HEALTH SERVICES
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Dates
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Enumeration Date | 10/26/2020
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Last Update Date | 04/06/2021
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Provider Practice Location Address
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Address Line | 7638 S EVANS AVE STE B
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City | CHICAGO
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State | IL
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Zip | 60619-2519
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Country | US
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Telephone | 728-201-6911
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Fax |
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Provider Business Mailing Address
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Address Line | 3685 JACKSON ST
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City | GARY
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State | IN
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Zip | 46408-1625
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Country | US
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Telephone | 872-201-6911
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANNETTE N DIGGS
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Credential | PMHNP-BC
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Telephone | 773-559-0393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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