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General NPI Number Information
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NPI Number | 1932983210
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Entity Type | Organization
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Legal Business Name | LAKE SHORE THERAPY GROUP
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Dates
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Enumeration Date | 08/21/2023
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Last Update Date | 07/16/2025
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Provider Practice Location Address
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Address Line | 307 N MICHIGAN AVE STE 412
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City | CHICAGO
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State | IL
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Zip | 60601-5318
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Country | US
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Telephone | 312-772-4768
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Fax |
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Provider Business Mailing Address
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Address Line | 540 W FRONTAGE RD STE 2235
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City | NORTHFIELD
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State | IL
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Zip | 60093-1228
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Country | US
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Telephone | 312-772-4768
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MR. JONATHAN COLLEDGE
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Credential | LCPC
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Telephone | 330-858-3312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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