MEDICARE: MR. ROGER LAKE MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFT17914	CA

General Provider Information

NPI Number	:	1033438700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER LAKE MFT

Provider Business Mailing Address
First Line	:	1325 COLUMBUS AVE
Second Line	:	TOP FLOOR
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94133-1303
Country	:	US
Telephone Number	:	415-567-7786
Fax Number	:	415-567-7786

Provider Business Practice Location Address
First Line	:	1325 COLUMBUS AVE
Second Line	:	TOP FLOOR
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94133-1303
Country	:	US
Telephone Number	:	415-567-7786
Fax Number	:	415-567-7786

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2010
Last Update Date	:	05/20/2010

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