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General NPI Number Information
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NPI Number | 1629900444
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Entity Type | Organization
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Legal Business Name | LAKE SUBSTANCE ABUSE SOLUTIONS LLC
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Dates
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Enumeration Date | 06/03/2026
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Last Update Date | 06/03/2026
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Provider Practice Location Address
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Address Line | 1143 FAIRWAY ST STE 103
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City | BOWLING GREEN
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State | KY
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Zip | 42103-2452
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Country | US
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Telephone | 812-901-6881
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Fax | 812-285-8392
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Provider Business Mailing Address
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Address Line | 1143 FAIRWAY ST STE 103
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City | BOWLING GREEN
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State | KY
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Zip | 42103-2452
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Country | US
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Telephone | 812-901-6881
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Fax | 812-285-8392
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Authorized Official
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Title or Position | OWNER
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Name | DAVID CORDDRY
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Credential |
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Telephone | 407-622-8086
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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