=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942241203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE BEHAVIORAL HEALTH ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 10/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5529B OSAGE BEACH PKWY
-----------------------------------------------------
City | OSAGE BEACH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65065-3023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-693-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 449
-----------------------------------------------------
City | OSAGE BEACH
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65065-0449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-693-9090
-----------------------------------------------------
Fax | 573-348-1858
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. NICOLE E. PARKER
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 573-693-9090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------