Provider Demographics
NPI:1114246535
Name:LAKE, CHRISTOPHER TODD (MPH,CDP)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:TODD
Last Name:LAKE
Suffix:
Gender:M
Credentials:MPH,CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-397-8228
Mailing Address - Fax:360-397-8259
Practice Address - Street 1:7700 NE 26TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-0672
Practice Address - Country:US
Practice Address - Phone:360-397-8228
Practice Address - Fax:360-397-8259
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004949101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)