Healthcare Provider Details

I. General information

NPI: 1750150678
Provider Name (Legal Business Name): LAKE AVENUE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 N LAKE AVE
PASADENA CA
91101-1213
US

IV. Provider business mailing address

393 N LAKE AVE
PASADENA CA
91101-1213
US

V. Phone/Fax

Practice location:
  • Phone: 626-817-4888
  • Fax: 626-817-4988
Mailing address:
  • Phone: 626-817-4888
  • Fax: 626-786-4988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. TSEGAMLAK WORKU
Title or Position: DIRECTOR OF COUNSELING
Credential: MFT
Phone: 626-786-1019