Provider Demographics
NPI:1053644377
Name:LAKE, ERIC S (MA,LLP, CADC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:LAKE
Suffix:
Gender:M
Credentials:MA,LLP, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8000
Mailing Address - Fax:616-840-9771
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5247
Practice Address - Country:US
Practice Address - Phone:616-840-8000
Practice Address - Fax:616-840-9771
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8952101YM0800X
NE121101YM0800X
MI6361002966103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47082303526Medicaid