Provider Demographics
NPI:1316412364
Name:LAKE, LISA (TREATMENT CONSULTANT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:TREATMENT CONSULTANT
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BEHAVIOR THERAPIST
Mailing Address - Street 1:3839 WALNUT PATH
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4884
Mailing Address - Country:US
Mailing Address - Phone:404-376-4780
Mailing Address - Fax:
Practice Address - Street 1:1776 CENTURY BLVD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3397
Practice Address - Country:US
Practice Address - Phone:678-974-2162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X, 171W00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor