Provider Demographics
NPI:1114413556
Name:LAK, JUSTIN JOHN (LICSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JOHN
Last Name:LAK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3600
Mailing Address - Country:US
Mailing Address - Phone:413-585-8071
Mailing Address - Fax:413-586-6776
Practice Address - Street 1:1 PRINCE ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3600
Practice Address - Country:US
Practice Address - Phone:413-585-8071
Practice Address - Fax:413-586-6776
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1199431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical