Provider Demographics
NPI:1578986923
Name:LAKE PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:LAKE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:DOWNS
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:803-699-8887
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-0707
Mailing Address - Country:US
Mailing Address - Phone:803-699-8887
Mailing Address - Fax:803-699-8824
Practice Address - Street 1:115 ATRIUM WAY
Practice Address - Street 2:SUITE 221
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6383
Practice Address - Country:US
Practice Address - Phone:803-699-8887
Practice Address - Fax:803-699-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC690103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty