Healthcare Provider Details

I. General information

NPI: 1710695531
Provider Name (Legal Business Name): DONITA MICHELLE LAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11225 FRONT ST
MOKENA IL
60448-1303
US

IV. Provider business mailing address

236 S PALMER DR
BOLINGBROOK IL
60490-6571
US

V. Phone/Fax

Practice location:
  • Phone: 708-537-7332
  • Fax:
Mailing address:
  • Phone: 708-580-2030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: