Basic Information
| Provider Information | |||||||||
| NPI: | 1346424520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE SHORE BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 430 NIAGARA ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142011886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Practice Location | |||||||||
| Address1: | LAKE SHORE BEHAVIORAL HEALTH | ||||||||
| Address2: | 254 FRANKLIN STREET | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2007 | ||||||||
| LastUpdateDate: | 12/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | HITZEL | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7168420440 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 261Q00000X | 02732658 | NY | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | MMIS#02732658 | 01 | NY | RISPERDAL CONSTA | OTHER |