Provider Demographics
NPI:1356467237
Name:OWENS & LAKE WELLNESS & COUNSELING, INC.
Entity Type:Organization
Organization Name:OWENS & LAKE WELLNESS & COUNSELING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS, LMHC
Authorized Official - Phone:321-632-5155
Mailing Address - Street 1:1209 ADMIRALTY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-632-5155
Mailing Address - Fax:321-632-5613
Practice Address - Street 1:1209 ADMIRALTY BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-632-5155
Practice Address - Fax:321-632-5613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8204101YM0800X
FLMH7448101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty