=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275496838
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATI NICOLE LAKE PHD, MS, MA, MPHIL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2025
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 BROADVIEW AVE
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10804-4145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-296-0220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 BROADVIEW AVE
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10804-4145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-296-0220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 027787
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------