Healthcare Provider Details

I. General information

NPI: 1801556899
Provider Name (Legal Business Name): JAMES EVAN LAKE MA, PC, ATR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2021
Last Update Date: 12/18/2021
Certification Date: 12/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 N CLEVELAND MASSILLON RD
FAIRLAWN OH
44333-2184
US

IV. Provider business mailing address

272 SOMERSET RD
AKRON OH
44313-4533
US

V. Phone/Fax

Practice location:
  • Phone: 330-723-7977
  • Fax: 330-239-8599
Mailing address:
  • Phone: 330-780-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number21-169
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.0008277
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: