Basic Information
| Provider Information | |||||||||
| NPI: | 1134331713 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE SHORE BEHAVIORAL HEALTH, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 254 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142021902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 S PARK AVE | ||||||||
| Address2: | |||||||||
| City: | LACKAWANNA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142181504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HITZEL | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7168420440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6783301A | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00671765 | 05 | NY | MEDICAID |