Basic Information
| Provider Information | |||||||||
| NPI: | 1386107746 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 LOUISIANA ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197571939 | ||||||||
| FaxNumber: | 2197571950 | ||||||||
| Practice Location | |||||||||
| Address1: | 8555 TAFT ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197694005 | ||||||||
| FaxNumber: | 2197571950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2019 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | SIKORA | ||||||||
| AuthorizedOfficialFirstName: | JUDITH | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2197571921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHLAKE COMMUNITY MENTAL HEALTH CNTR | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
| ID | Type | State | Issuer | Description | 100157670 | 05 | IN | MEDICAID |