Provider Demographics
NPI:1437738374
Name:LAKE, AUTUMN LEIGH
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:LEIGH
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4340 ELM LAWN RD
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-9656
Mailing Address - Country:US
Mailing Address - Phone:715-330-1773
Mailing Address - Fax:920-260-2023
Practice Address - Street 1:4340 ELM LAWN RD
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-9656
Practice Address - Country:US
Practice Address - Phone:920-944-9373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT21159367103K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst