Healthcare Provider Details

I. General information

NPI: 1104754720
Provider Name (Legal Business Name): LAKE THERAPY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 45TH ST S STE B
FARGO ND
58104-8955
US

IV. Provider business mailing address

3003 32ND AVE S STE 240
FARGO ND
58103-6118
US

V. Phone/Fax

Practice location:
  • Phone: 701-419-6948
  • Fax:
Mailing address:
  • Phone: 701-419-6948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ERIKA LAKE
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 701-219-9553