Provider Demographics
NPI:1518241330
Name:LAKE, JAMES P (MS, LCPC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:P
Last Name:LAKE
Suffix:
Gender:M
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N MAIN ST APT E304
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-1759
Mailing Address - Country:US
Mailing Address - Phone:847-526-6425
Mailing Address - Fax:847-526-6425
Practice Address - Street 1:440 N MAIN ST APT E304
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-1759
Practice Address - Country:US
Practice Address - Phone:847-526-6425
Practice Address - Fax:847-526-6425
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007410101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional