Provider Demographics
NPI:1033702287
Name:LAKE, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 NE 44TH AVE STE 390
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1461
Mailing Address - Country:US
Mailing Address - Phone:503-963-6494
Mailing Address - Fax:
Practice Address - Street 1:1827 NE 44TH AVE STE 390
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1461
Practice Address - Country:US
Practice Address - Phone:503-963-6494
Practice Address - Fax:310-933-4134
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
ORABA-B-10228550103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician