=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528946845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE THERAPEUTIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2025
-----------------------------------------------------
Last Update Date | 08/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 W CHISHOLM ST
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-2446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-461-4825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 W CHISHOLM ST
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-2446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-461-4825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY CRITTENDEN
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 989-464-8871
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------