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General NPI Number Information
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NPI Number | 1144012105
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Entity Type | Organization
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Legal Business Name | LAKE WELLNESS COLLECTIVE
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Dates
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Enumeration Date | 05/17/2025
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Last Update Date | 05/17/2025
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Provider Practice Location Address
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Address Line | 8609 PARK AVE
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City | BOWIE
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State | MD
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Zip | 20720-3698
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Country | US
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Telephone | 301-615-0883
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Fax |
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Provider Business Mailing Address
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Address Line | 8609 PARK AVE
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City | BOWIE
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State | MD
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Zip | 20720-3698
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LEAD THERAPIST
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Name | MARVIDA FRANCES LAKE
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Credential | LCPC
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Telephone | 919-741-3481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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