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General NPI Number Information
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NPI Number | 1669094967
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Entity Type | Organization
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Legal Business Name | CANDACE LAKE MS LMHC PA
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Dates
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Enumeration Date | 05/11/2020
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Last Update Date | 05/11/2020
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Provider Practice Location Address
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Address Line | 1650 NE 26TH ST STE 201
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City | WILTON MANORS
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State | FL
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Zip | 33305-1431
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Country | US
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Telephone | 561-271-0681
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Fax |
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Provider Business Mailing Address
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Address Line | 2883 NE 15TH ST
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City | POMPANO BEACH
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State | FL
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Zip | 33062-3611
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Country | US
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Telephone | 561-271-0681
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. CANDACE RENEE LAKE
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Credential | MS
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Telephone | 561-271-0681
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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