Basic Information
| Provider Information | |||||||||
| NPI: | 1245742469 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE ERIE BEHAVIORAL HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3216 STATE ST | ||||||||
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| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144543192 | ||||||||
| FaxNumber: | 8144543190 | ||||||||
| Practice Location | |||||||||
| Address1: | 3216 STATE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148122633 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2017 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | HERON | ||||||||
| AuthorizedOfficialFirstName: | SHERIFIA | ||||||||
| AuthorizedOfficialMiddleName: | ELAINE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8144543192 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | MD458004 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.