NPIMap

Organization Active NPI

Southlake Community Mental Health Center, Inc.

Doing business as Regional Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Merrillville, IN
National Provider Identifier
1477007292
Registry record updated Aug 15, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER, INC.
Doing business as
Regional Health Clinic
Practice address
8555 Taft St
Merrillville, IN 46410-6123
Phone
(219) 937-3300
Fax
(219) 757-1950
NPI assigned
Aug 10, 2016
Last updated
Aug 15, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 15, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert Krumwied
Title
Ceo
Phone
(219) 769-4005

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Multi-Specialty Clinic/Center 261QM1300X

Addresses

Primary practice location

8555 Taft St
Merrillville, IN 46410-6123

Mailing address

8400 Louisiana St
Merrillville, IN 46410-6385
Phone (219) 757-1924

Other names 1

  • Regional Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN4 enrollments

Enrollment records 4

Enrollment IDStateProvider typePAC IDDetails
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
O20170726002650 IN Part A Provider - Federally Qualified Health Center (FQHC) 5991600355 Practice locations: Merrillville, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1477007292. Details of each certification follow.

Federally qualified health center certification: CCN 151009

Legal name
SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER INC
Doing business as
REGIONAL MENTAL HEALTH-STRAWHUN CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 26, 2017
Last certification
Jul 26, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Aug 14, 1975 in IN
Enrollment address
8555 Taft St
Merrillville, IN 46410-6123

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 11

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D2131942Regional Health Clinic8555 Taft St, Merrillville, IN 46410Certificate of waiverJun 7, 2027
15D2296719Regional Health Clinic - Mobile Unit8555 Taft Street, Room 101, Merrillville, IN 46410Certificate of waiverJan 3, 2028

National Provider Directory

National Provider Directory
Tax ID family
Southlake CMHC10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2600 Highway Ave
Highland, IN 46322
Phone (219) 757-1953

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Carla Houck Individual Corporate OfficerBoard Chair May 13, 2024
Corporate DirectorBoard Chair May 13, 2024
Thomas O'Donnell Individual Corporate DirectorBoard Member Dec 31, 2019
Danny Lackey Individual Corporate DirectorBoard Member Dec 31, 2019
Carol Drasga Individual Corporate OfficerBoard Member Dec 13, 2013
Daniel Klien Individual Corporate OfficerBoard Member May 13, 2024
Amy Han Individual Corporate OfficerBoard Member Dec 13, 2013
Southlake Community Mental Health Center Inc Organization, Merrillville, IN Corporation 5% Or Greater Direct Ownership Interest Aug 14, 1975 100%
Linda Jonaitis Individual Corporate OfficerVice President Dec 13, 2013
Gary Johnson Individual Corporate OfficerBoard Member May 13, 2024
Donald Levinson Individual Corporate OfficerBoard Member Dec 13, 2013
Jonathan Petersen Individual Corporate OfficerBoard Member May 13, 2024
William Trowbridge Individual Corporate OfficerPresident/Ceo May 13, 2024
Corporate DirectorDirector of Finance May 13, 2024
Lashaun Woods Individual Corporate OfficerDirector of Finance May 13, 2024
Corporate DirectorDirector of Finance May 13, 2024
W-2 Managing EmployeeDirector of Finance May 13, 2024
Operational/Managerial ControlDirector of Finance May 13, 2024

Owners & managing parties with NPI records 6

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 24

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1470787200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692057600000",
    "number": "1477007292",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8400 LOUISIANA ST",
            "city": "MERRILLVILLE",
            "state": "IN",
            "postal_code": "464106385",
            "telephone_number": "219-757-1924",
            "fax_number": "219-757-1928"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8555 TAFT ST",
            "city": "MERRILLVILLE",
            "state": "IN",
            "postal_code": "464106123",
            "telephone_number": "219-937-3300",
            "fax_number": "219-757-1950"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-08-10",
        "last_updated": "2023-08-15",
        "certification_date": "2023-08-15",
        "status": "A",
        "authorized_official_last_name": "KRUMWIED",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "219-769-4005"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Regional Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Regional Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Merrillville, IN

Sources for this page

Verify at the official NPI Registry.