Provider Demographics
NPI:1457332835
Name:LAKE, PATRICIA MARY (LPCC)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:MARY
Last Name:LAKE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CANDELARIA RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-2915
Mailing Address - Country:US
Mailing Address - Phone:505-925-2493
Mailing Address - Fax:505-925-2491
Practice Address - Street 1:2450 ALAMO AVE SE
Practice Address - Street 2:MILAGRO PROGRAM
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3204
Practice Address - Country:US
Practice Address - Phone:505-925-2493
Practice Address - Fax:505-925-2491
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3297101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79973337Medicaid