Healthcare Provider Details

I. General information

NPI: 1184735532
Provider Name (Legal Business Name): ALAN HARRIS LAKE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 OLD ORCHARD RD
BLOOMFIELD CT
06002-2259
US

IV. Provider business mailing address

9 OLD ORCHARD RD
BLOOMFIELD CT
06002-2259
US

V. Phone/Fax

Practice location:
  • Phone: 860-402-4402
  • Fax:
Mailing address:
  • Phone: 860-402-4402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number000875
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000875
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: