Basic Information
| Provider Information | |||||||||
| NPI: | 1790273308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES NP OF PSYCHIATRY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 61 | ||||||||
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| City: | EAST AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140510061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169081711 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3802 SENECA ST | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142243433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166775418 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2018 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | LOPEZ | ||||||||
| AuthorizedOfficialFirstName: | LORRAINE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7169081711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PMHNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | F400896 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.