MEDICARE: MELISSA LAKE LAC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1659182764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA LAKE LAC

Provider Business Mailing Address
First Line	:	1517 W LOMA LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-5443
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7325 N 16TH ST STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-5202
Country	:	US
Telephone Number	:	602-345-0276
Fax Number	:

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

Provider Enumeration Date	:	01/17/2025
Last Update Date	:	01/17/2025

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Directions to “ MELISSA LAKE LAC” Practice Location

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