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NPI Code Detail

MEDICARE: JOHN M LAKE MSW, LISW

MEDICARE: JOHN M LAKE MSW, LISW
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
1101YM0800XMental Health CounselorLH0005634WA

General Provider Information

NPI Number : 1861561367
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN M LAKE MSW, LISW
Provider Business Mailing Address
First Line : 746 N OAK ST
Second Line :
City : COLVILLE
State : WA
Zip : 99114-3148
Country : US
Telephone Number : 509-684-6172
Fax Number :
Provider Business Practice Location Address
First Line : 165 E HAWTHORNE AVE
Second Line :
City : COLVILLE
State : WA
Zip : 99114-2629
Country : US
Telephone Number : 509-684-6172
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/07/2006
Last Update Date : 07/08/2007

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