Provider Demographics
NPI:1386107746
Name:SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIKORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-757-1921
Mailing Address - Street 1:8400 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6385
Mailing Address - Country:US
Mailing Address - Phone:219-757-1939
Mailing Address - Fax:219-757-1950
Practice Address - Street 1:8555 TAFT ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6123
Practice Address - Country:US
Practice Address - Phone:219-769-4005
Practice Address - Fax:219-757-1950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHLAKE COMMUNITY MENTAL HEALTH CNTR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100157670Medicaid