Healthcare Provider Details

I. General information

NPI: 1033702287
Provider Name (Legal Business Name): ELIZABETH NICOLE LAKE MA, BCBA/LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 BROADSTONE PKWY APT 2307
FOLSOM CA
95630-6698
US

IV. Provider business mailing address

1550 BROADSTONE PKWY APT 2307
FOLSOM CA
95630-6698
US

V. Phone/Fax

Practice location:
  • Phone: 805-297-0029
  • Fax:
Mailing address:
  • Phone: 805-297-0029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-63133
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-63133
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: