Provider Demographics
NPI:1598136665
Name:LAKE PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:LAKE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TANNEN
Authorized Official - Middle Name:
Authorized Official - Last Name:STAHLEY-LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:724-465-2311
Mailing Address - Street 1:163 PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3264
Mailing Address - Country:US
Mailing Address - Phone:724-465-2311
Mailing Address - Fax:724-465-2339
Practice Address - Street 1:163 PLAZA RD
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3264
Practice Address - Country:US
Practice Address - Phone:724-465-2311
Practice Address - Fax:724-465-2339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015411103TC0700X
PAPS017929103TC0700X
PACW0173591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty