Provider Demographics
NPI:1629218656
Name:LAKE, KIMBERLY MARIE (MA)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:MARIE
Last Name:LAKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 95TH ST
Mailing Address - Street 2:15F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-4077
Mailing Address - Country:US
Mailing Address - Phone:781-720-8212
Mailing Address - Fax:
Practice Address - Street 1:215 E 95TH ST
Practice Address - Street 2:15F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-4077
Practice Address - Country:US
Practice Address - Phone:781-720-8212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1958934103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst