Southlake Community Mental Health Center, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · East Chicago, IN
NPI 1376919217 · NPPES record last updated Jul 1, 2016
Key facts
- NPI
- 1376919217
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER, INC
- Practice address
- 3903 Indianapolis Blvd
East Chicago, IN 46312-2555 - Phone
- (219) 398-7050
- Fax
- (219) 392-6998
- NPI assigned
- Aug 14, 2015
- Organization subpart
- No
Authorized official
- Name
- Robert Krumwied
- Title
- Ceo
- Phone
- (219) 736-7183
Owned or controlled facilities with NPI records 1
Other NPIs on the same Medicare enrollment 11
Other NPIs with the same Medicare PAC ID 6
Corporate family (same tax ID) 9
Practitioners 37
-
Jazmine Kara Larson, APRN
-
Krishn Mohan, M.D.
-
Heidi E Badgely, LCSW
-
Regina Baron, LMHC
-
Archana Barry, M.D.
-
Robert Beedle, PHD
-
Theresa M Cieslinski, PFMHNP
-
Kobie I Douglas, MD
-
Joseph G Fanelli, MD
-
Lucinda Franco, BA
-
Rujuta R Gandhi, M.D.
-
Tamara Marie Grzesik, LMHC
-
Michelle Lynn McBrayer, LCSW
-
Shawn McClure, MSN APN PMHNP-BC
-
Anthony Pellegrini, LCSW
-
Valerie Perez, PSYD/ HSPP
-
Latasha Pittman, NP
-
Rachel Santay, MD
-
Hugh B Starks, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 15D2100511 | Regional Health Clinic | Certificate of waiver | Aug 16, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (4 enrollments) in IN
Federally qualified health center certification: CCN 151958
- Legal name
- SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC
- Doing business as
- REGIONAL HEALTH CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 18, 2015
- Last certification
- Sep 18, 2015
- Ownership / control type
- For profit – partnership
- Organization structure
- Corporation · Non-profit
- Incorporated
- Aug 14, 1975 in IN
- Enrollment address
- 3903 Indianapolis Blvd
East Chicago, IN 46312-2555
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Carla Houck |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Thomas O'Donnell |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Danny Lackey |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Carol Drasga |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Daniel Klien |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Amy Han |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Linda Jonaitis |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Gary Johnson |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Donald Levinson |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| Jonathan Petersen |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| William Trowbridge |
Corporate Officer |
May 13, 2024 | |
| Corporate Director |
May 13, 2024 | ||
| W-2 Managing Employee |
May 13, 2024 | ||
| Lashaun Woods |
Corporate Officer |
May 13, 2024 | |
| W-2 Managing Employee |
May 13, 2024 | ||
| Operational/Managerial Control |
May 13, 2024 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Regional Mental Health-Strawhun Center |
Federally qualified health center | 5% Or Greater Direct Ownership Interest (100%) | Aug 14, 1975 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031201000049 | IN | Part B Supplier - Clinic/Group Practice | 5991600355 |
Receives reassigned benefits from 38 practitioners 11 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Hammond, IN; Merrillville, IN; Hobart, IN; East Chicago, IN; Highland, IN |
| O20031231000117 | IN | Part B Supplier - Clinic/Group Practice | 5991600355 |
Receives reassigned benefits from 33 practitioners 11 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: East Chicago, IN; Hammond, IN; Highland, IN; Hobart, IN; Merrillville, IN |
| O20040513000199 | IN | Part B Supplier - Clinic/Group Practice | 5991600355 |
Receives reassigned benefits from 19 practitioners 11 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Hobart, IN; Merrillville, IN; Highland, IN; Hammond, IN; East Chicago, IN |
| O20150921001324 | IN | Part a Provider - Federally Qualified Health Center (FQHC) | 5991600355 | Practice locations: East Chicago, IN |
National Provider Directory
- Tax ID family
- Southlake Community Mental Health Center Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
3903 Indianapolis Blvd
East Chicago, IN 46312-2555
Mailing address
8400 Louisiana St
Merrillville, IN 46410-6385
Phone (219) 757-1924
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 201323280A | Medicaid | IN | |
| 15D2100511 | Other | IN | CLIA |
Other names
- Regional Health Clinic
Other providers in East Chicago, IN
- Sheilonda Smith
- Talashia Smith
- Veronica Smith
- David Soderquist
- Southlake Community Mental Health Center Inc.
- Scarlet Rae Spain
- Bridgette Leora Spann Edwards
- Spine & Musculoskeletal Center PC
- Joseph Phillip Spott
- St Catherine Hospital Inc
All providers in East Chicago, IN · Federally Qualified Health Center (FQHC) in Indiana
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 1, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.