Basic Information
| Provider Information | |||||||||
| NPI: | 1972092047 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 LOUISIANA ST | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197571924 | ||||||||
| FaxNumber: | 2197571950 | ||||||||
| Practice Location | |||||||||
| Address1: | 3903 INDIANAPOLIS BLVD | ||||||||
| Address2: | |||||||||
| City: | EAST CHICAGO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193987050 | ||||||||
| FaxNumber: | 2193923998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2018 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROLL | ||||||||
| AuthorizedOfficialFirstName: | SHIRLEY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 3174727396 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 424-014 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.