=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457675225
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANA LAKE LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2010
-----------------------------------------------------
Last Update Date | 07/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 LAKE COOK RD SUITE 113
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-331-1505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 LAKE COOK RD SUITE 113
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-331-1505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180.006946
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------