Provider Demographics
NPI:1891058947
Name:LAKE, STEPHANIE J (CATC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:LAKE
Suffix:
Gender:F
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE SHIELDS AVE
Mailing Address - Street 2:UC DAVIS STUDENT HEALTH AND COUSELING SERVICES
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616
Mailing Address - Country:US
Mailing Address - Phone:530-752-6334
Mailing Address - Fax:530-752-4252
Practice Address - Street 1:ONE SHIELDS AVE
Practice Address - Street 2:UC DAVIS STUDENT HEALTH AND COUSELING SERVICES
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616
Practice Address - Country:US
Practice Address - Phone:530-752-6334
Practice Address - Fax:530-752-4252
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACATC #091698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist