Provider Demographics
NPI:1083267306
Name:LAKE, PYPER SHAE
Entity Type:Individual
Prefix:
First Name:PYPER
Middle Name:SHAE
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 1:4273 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-5321
Mailing Address - Country:US
Mailing Address - Phone:989-953-4357
Mailing Address - Fax:
Practice Address - Street 1:4273 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-5321
Practice Address - Country:US
Practice Address - Phone:989-953-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician