Provider Demographics
NPI:1407628845
Name:LAKE, DAKOTA MICHEAL (CSWA)
Entity Type:Individual
Prefix:MR
First Name:DAKOTA
Middle Name:MICHEAL
Last Name:LAKE
Suffix:
Gender:M
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5881 N MONTANA AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4681
Mailing Address - Country:US
Mailing Address - Phone:616-821-6584
Mailing Address - Fax:
Practice Address - Street 1:2355 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:971-415-5755
Practice Address - Fax:971-415-5855
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA131881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical