Healthcare Provider Details

I. General information

NPI: 1043964133
Provider Name (Legal Business Name): OLIVIA CLAIRE LAKES LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 18TH ST NW
WASHINGTON DC
20009-1812
US

IV. Provider business mailing address

272 GALLIVAN BLVD
BOSTON MA
02124-4733
US

V. Phone/Fax

Practice location:
  • Phone: 857-212-3444
  • Fax:
Mailing address:
  • Phone: 857-212-3444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200002485
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: