Provider Demographics
NPI:1871008367
Name:LAKE, STEPHANIE DENISE (LMSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DENISE
Last Name:LAKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23131 MICHIGAN AVE # 1168
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2020
Mailing Address - Country:US
Mailing Address - Phone:313-608-5544
Mailing Address - Fax:
Practice Address - Street 1:3501 HARDING ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3731
Practice Address - Country:US
Practice Address - Phone:313-608-5544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801109246104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical