Healthcare Provider Details

I. General information

NPI: 1538638622
Provider Name (Legal Business Name): WHITNEY LAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 DELTONA BLVD STE A
DELTONA FL
32725-8016
US

IV. Provider business mailing address

245 GRACEY CV
GENEVA FL
32732-8419
US

V. Phone/Fax

Practice location:
  • Phone: 386-259-5413
  • Fax:
Mailing address:
  • Phone: 407-505-9744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH17405
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: