Provider Demographics
NPI:1699863316
Name:LAKE COUNTY SHERIFFS OFFICE JAIL TREATMENT PROGRAM
Entity type:Organization
Organization Name:LAKE COUNTY SHERIFFS OFFICE JAIL TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:BA CCDCIIIE
Authorized Official - Phone:440-350-5669
Mailing Address - Street 1:104 EAST ERIE STREET
Mailing Address - Street 2:LAKE COUNTY SHERIFFS OFFICE SUITE 320
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-3910
Mailing Address - Country:US
Mailing Address - Phone:440-350-5669
Mailing Address - Fax:440-350-5668
Practice Address - Street 1:104 EAST ERIE STREET
Practice Address - Street 2:SUITE 320
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-3910
Practice Address - Country:US
Practice Address - Phone:440-350-5669
Practice Address - Fax:440-350-5668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6655251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000006655Medicare UPIN