Provider Demographics
NPI:1679637672
Name:LAKE, LINDA LOUISE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:LOUISE
Last Name:LAKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E OGDEN AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3542
Mailing Address - Country:US
Mailing Address - Phone:630-325-5300
Mailing Address - Fax:630-325-5309
Practice Address - Street 1:120 E OGDEN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3542
Practice Address - Country:US
Practice Address - Phone:630-325-5300
Practice Address - Fax:630-325-5309
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02215636OtherBLUE CROSS BLUE SHIELD
IL2081732Medicare ID - Type Unspecified