MEDICARE: LAKE PSYCHOLOGICAL SERVICES, LLC

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	103TC0700X	Clinical Psychologist	690	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225061971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE PSYCHOLOGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	115 ATRIUM WAY
Second Line	:	SUITE #221
City	:	COLUMBIA
State	:	SC
Zip	:	29223-6383
Country	:	US
Telephone Number	:	803-699-8887
Fax Number	:	803-699-8824

Provider Business Practice Location Address
First Line	:	115 ATRIUM WAY
Second Line	:	SUITE #221
City	:	COLUMBIA
State	:	SC
Zip	:	29223-6383
Country	:	US
Telephone Number	:	803-699-8887
Fax Number	:	803-699-8824

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KAREN DOWNS LAKE
Credential	:	PH.D.
Telephone Number	:	803-699-8887

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	01/17/2014

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