Healthcare Provider Details

I. General information

NPI: 1497105233
Provider Name (Legal Business Name): LAKE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGHLANDS DR SUITE 301C
LITITZ PA
17543-7693
US

IV. Provider business mailing address

100 HIGHLANDS DR SUITE 301C
LITITZ PA
17543-7693
US

V. Phone/Fax

Practice location:
  • Phone: 717-575-3757
  • Fax: 717-620-3285
Mailing address:
  • Phone: 717-575-3757
  • Fax: 717-620-3285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number127241
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ALEXIS LAKE
Title or Position: OWNER/THERAPIST
Credential: LSW
Phone: 717-575-3757