Healthcare Provider Details

I. General information

NPI: 1720533581
Provider Name (Legal Business Name): MICHELLE LAKE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELE A CAMPA

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-5971
  • Fax: 517-789-5918
Mailing address:
  • Phone: 313-874-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401017419
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: