Provider Demographics
NPI:1629643283
Name:LAKE, RENEE ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:ANNE
Last Name:LAKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 PARK WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7246
Mailing Address - Country:US
Mailing Address - Phone:315-521-3166
Mailing Address - Fax:
Practice Address - Street 1:3003 DUNES WEST BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-8001
Practice Address - Country:US
Practice Address - Phone:843-352-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4708103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty