Provider Demographics
NPI:1144818295
Name:GREAT LAKES BEHAVIORAL SERVICES
Entity type:Organization
Organization Name:GREAT LAKES BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:574-393-9955
Mailing Address - Street 1:701 N NILES AVE STE OP102
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1923
Mailing Address - Country:US
Mailing Address - Phone:574-393-9955
Mailing Address - Fax:574-393-9956
Practice Address - Street 1:701 N NILES AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1923
Practice Address - Country:US
Practice Address - Phone:574-393-9955
Practice Address - Fax:574-393-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty